Safe Surgery Checklists May Raise Unintended Ethical and Legal Questions, Especially in Low-Resource Settings

By Matt Baum

The WHO Surgical Safety Checklist is unusual as a patient-safety intervention in that it has been widely promoted as universally effective, i.e. effective both in high-income and resource-limited settings; checklists are now used in approximately 1800 hospitals worldwide. In a paper recently published in the journal, BMJ Open, Aveling and colleagues report the results of a qualitative study on the implementation of the WHO checklist in two UK hospitals and two hospitals in resource-constrained settings in Africa.  Their results suggest that the checklist is “no magic bullet” – that if adopted without proper investment and adaptation to the context of the target hospital, the checklist not only may fail to replicate benefits, but can actually levy its own unintended costs – especially in resource-limited settings. Though the study raises a number of interesting questions, given the nature of this blog, I am hoping that we might start a discussion about  those in the domain of ethics and law.

For example, consider the following real case, which was reported in the BMJ paper:

“A patient admitted for cholecystectomy [surgical removal of the gallbladder] suffered hypoxic [oxygen depriviation-related] brain injury and died following surgery. Subsequently, two staff members (not the surgeon) were threatened with guns by the patient’s family, who said that the surgical team had killed the patient. The two staff members were later arrested and criminal charges brought against one of them. One of the questions asked during the police investigation was whether a pulse oximeter [i.e. a tool for measuring blood-oxygen levels] had been used. It had not: according to staff, no pulse oximeter was available for use, even though the checklist requiring use of this equipment was, officially, in use at the hospital.”

The staff members also did not get any legal representation for weeks because there were no clear policies established surrounding who was responsible for providing that counsel.

This case raises significant questions about the individual, institutional, and promoter responsibilities regarding checklists; I am hoping we can begin to discuss these questions in the comments section. To give us a prompt: who should be blamed?

  • The staff members: it is their responsibility to put on the pulse oximeter.
  • The surgeon: the surgeon should not have performed the surgery without complying with the hospital’s official policies.
  • The hospital: the hospital should not have adopted the checklist as an official policy without securing resources necessary to comply with it.
  • The checklist promoters: they should not have promoted the checklist in this setting without addressing the resource and training needs specific to that context and necessary to implement the checklist successfully.

This case is obviously an extreme example. Because the checklist makes certain assumptions about context (availability of malpractice insurance, hospital practices, hierarchies, goals, training) it might not be so uncommon that there are significant or insurmountable barriers to successfully meeting a requirement of a checklist. The existence of such a barrier would re-create a similarly vulnerable situation if the checklist is adopted as policy without also addressing the barrier. For example, the checklist requires equipment-counts at the end of surgery, but in some hospitals, nurses may have neither received training in nor been exposed to the practice, which would lead to a significant barrier to the proper completion of that requirement.

Thus adaptation and investment of time and resources (e.g. implementing training on equipment counts) may be required for responsible promotion and implementation of checklists.

What do you think?


During his fellowship, Matthew Baum was a second year MD-PhD student in the Health Science and Technology (HST) combined program of Harvard and MIT where he integrated his interests in clinical, scientific, and ethical aspects of mental health. He holds a DPhil at the Oxford Centre for Neuroethics where his doctoral work, supported by a Rhodes Scholarship, concerned the ethical implications of the development of predictive biomarkers of brain disorders. Matthew also completed an MSc in Neuroscience at Trinity College Dublin as a George Mitchell Scholar and holds a BS and an MS in Molecular Biology from Yale. During his medical and neuroscience training he maintained a strong engagement with neuroethics; he has acted as the student representative to the International Society for Neuroethics. During his time at the Petrie-Flom Center, Matt researched the intersection of biological risk and disorder.

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