Developing Tools to Improve Surgical Safety 

A surgical procedure is a complex event, requiring careful coordination among multiple teams to ensure that all safety protocols are followed. Whether the procedure goes according to plan, or if unexpected emergencies occur, teamwork and communication are critical to ensuring the best possible outcomes for the patient. Ariadne Labs has developed tools to support surgical teams during routine procedures and crisis situations.

WHO Surgical Safety Checklist


This checklist template is designed for all three sections (Before induction of anesthesia, before skin incision, and before patient leaves the room) to be performed in the operating room. This checklist doesn’t preclude or change any of the existing routines you have in your preoperative area.

The World Health Organization (WHO) Surgical Safety Checklist aims to improve surgical outcomes by outlining a series of steps taken before, during, and after a procedure to ensure surgical teams follow all safety protocols. In 2008, the WHO adopted the Surgical Safety Checklist as the global standard of care, and the Checklist became a core program of Ariadne Labs in 2012.

The Checklist identifies three critical pause points for surgery:

  1. Before the induction of anesthesia,
  2. Before the incision in the skin, and
  3. Before the patient leaves the operating room.

At each pause point, the Checklist encourages preparation, communication, and adherence to important practices that reduce errors and help surgical teams work together. By using the Checklist to build effective communication and teamwork, surgical teams can minimize the most common and avoidable risks.

Ariadne Labs collaborates with hospitals and medical facilities around the world to implement, evaluate, and adapt the Checklist. 

Studies have been conducted around the world to understand the effects of the checklist on surgical safety, with most findings pointing to a positive impact. For example, in the first study of country-level impact of the Checklist, Scotland saw a 36.6 percent reduction in post-surgical deaths since implementing the Checklist as part of a national health safety program. 

Uptake of the Checklist has been widespread. A 2020 report on the first decade of the WHO Surgical Safety Checklist, Checking In On the Checklist, found that facilities in 70% of the world’s countries attest to using it, though more work remains to disseminate the Checklist in diverse settings. Beyond its clinical effects, users say the Checklist has been instrumental in introducing a culture of safety, improving communication, strengthening efficiency, increasing trust, and empowering practitioners. 

Operating Room Crisis Checklists


The OR Crisis Checklists were developed by the team at Ariadne Labs with the goal of improving care during 12 of the most common operating room crises. The checklists were updated in May 2017.

The Operating Room (OR) Crisis Checklists are a compendium of 12 checklists to guide surgical teams during unexpected, critical events in the OR, modeled after the WHO Surgical Safety Checklist. 

Crises such as patient cardiac arrest or hemorrhage are rare during procedures in ORs, but when they occur, they require a rapid, effective response from the surgical team to ensure a good outcome for the patient. However, surgical teams are more likely to forget important steps when in an emergency or under stress. 

The Ariadne Labs team used our experience in developing and modifying surgical safety checklists to create a tool that addresses unpredictable and dangerous events in the OR.

In testing in medical simulations, clinical teams using the OR Crisis Checklists completed nearly 100 percent of the proven life-saving steps necessary in an emergency, as compared to only 77 percent among teams not using the tools. The findings reflect a 75 percent reduction in missed steps.

To expand the reach of the Checklists, Ariadne Labs collaborated with Stanford University to launch an online implementation toolkit Implementing Emergency Checklists website in October 2017. The website provides the resources and tools health care leaders and clinical teams need to effectively integrate the OR Crisis Checklists into their practices.

Additionally, while Ariadne Labs was developing and testing the original OR Crisis Checklists in 2011, the Stanford Anesthesia Cognitive Aid Group launched the Stanford Perioperative Emergency Manual. This compilation of 23 protocols is designed for real-time clinical use, was tested in simulated crises, and was implemented with all Stanford operating personnel in 2012. Ariadne Labs and Stanford then brought their complementary streams of work together, forming the Emergency Manual Implementation Collaborative (EMIC).