Intended for healthcare professionals

Opinion Dissecting Health

Scarlett McNally: Surgical checklists help improve patient safety and teamworking

BMJ 2023; 380 doi: (Published 09 February 2023) Cite this as: BMJ 2023;380:p279
  1. Scarlett McNally, professor
  1. Eastbourne
  1. scarlettmcnally{at}
    Follow Scarlett on Twitter @scarlettmcnally

Decades ago, just before operating I used to recite a silent, non-religious prayer that it would go well. In the hustle and bustle of ward rounds and preparation this was a personal, solitary moment of calm. I was delighted when a “team brief” was made mandatory, involving sharing details and preparing contingency plans with a supportive team. We all need a last minute prompt, especially when we’re distracted or have tunnel vision.

Multiple reports cataloguing patient safety issues have been published in recent years. A report from last year suggests that 9% of hospital treatments or procedures involve a patient safety incident.1 When something goes wrong there’s often a flurry of blame and regret, as though each failing is seen as an isolated incident. Most failings, however, result from cultural factors, such as misunderstandings, or from mismatched expectations, especially between staff in different professional groups. A 2019 report found poor teamworking in 76% of 100 suboptimal surgical departments visited by the Royal College of Surgeons of England’s “invited review mechanism.”2

Reports keep coming on “why” these failings happen. What we need instead is a recipe for “how” to prevent them: a dossier of standards detailing how to change has now been launched and could prove highly effective.3 Written by clinicians, the updated National Patient Safety Standards for Invasive Procedures (NatSSIPs 2) aim to improve patient safety and teamworking. The standards apply to all invasive procedures, including those in outpatients, emergency departments, delivery suites, and interventional radiology departments, with “proportionate checks” for less complex procedures.

The original NatSSIPs were designed to prevent “never events”—yet more than 300 occurrences of wrong site surgery, retained objects after procedure, or wrong implant insertion still occur yearly in the UK.4 NatSSIPs 2 brings in safety science and human factors, with expectations for organisations including standardisation, harmonisation, training, and audit. For clinicians, eight sequential steps define what should happen for every patient in every procedure. This goes further than the five components of the World Health Organization’s checklist of team brief, sign-in, time out, sign-out, and debrief. NatSSIPs 2 has three additional steps: consent with marking and verification; implant checks; and re-counting of items to prevent retained equipment or swabs.

The NHS currently faces staff shortages, burnout, large backlogs, and patients with more complex conditions due to treatment delays during the pandemic. With huge workforce challenges some staff may be redeployed, and teams can be transient. The eight steps in NatSSIPs 2 mean that every person involved, including new staff and students, should have a clear and consistent understanding of what should happen and be valued as a team member. Patients are encouraged to be involved and to consider these checks like airport security.

There are other benefits too. Prompts to confirm which kit should be opened can reduce waste and improve sustainability. Valuing each team member may help reduce burnout and resignations. A surgeon giving probable timings for each case can facilitate better planning and enable staff to take breaks.

Healthcare staff are working in high pressure environments. Embedding standards that encourage us to plan ahead with team members helps to break down silo working. It also allows for questions that may be obvious to some but that the whole team must understand. Every step is designed to be consistent yet individualised for each patient.

The biggest danger is if the new standards sit on the shelf. With their benefits for patient safety and teamworking, we must accept the repetitive elements and consistently apply these new standards, every time, in every department.


  • Competing interests: Scarlett McNally is deputy director of the Centre for Perioperative Care ( The centre pays her NHS trust 1 PA (one half day a week) for her time.

  • Provenance and peer review: commissioned, not externally peer reviewed.