Integrating the Surgical Safety Checklist into Labor & Delivery

Achieving a safe delivery requires adherence to evidence-based practice and national guidelines, yet adapting these standards to the obstetric setting can be complex. The Surgical Safety Checklist (SSC), developed by experts within the World Health Organization, has been shown to significantly decrease inpatient surgical complications and death. It includes 3 key parts: (1) preoperative briefing before anesthesia induction, (2) Time-out prior to skin incision, and (3) postoperative debriefing before the patient leaves the room (WHO, 2009). 

Successfully integrating the surgical safety checklist in labor and delivery (L&D) units may be challenging due to the operational differences between obstetric and traditional surgical settings. L&D units function in multiple capacities- serving as emergency departments for pregnant patients, managing acute labor and antepartum care, and providing standard operating room services. The flow of the unit is continuously changing due to the unpredictability of unplanned admissions and unexpected cesarean deliveries. In addition, cesarean delivery requires the collaboration of multiple specialties (Obstetrics, Neonatal/Pediatrics, and Anesthesia) and consideration for both mother and infant(s) (Patel et al., 2024). Due to these operational differences, the SSC may not be seen as value-added.  

The surgical safety checklist encompasses many critical aspects of operative safety, applicable to patients across all settings. It goes beyond confirming the right patient and procedure,  reinforcing equipment checks, communication of anticipated problems, and adherence to antibiotic prophylaxis. It promotes a shared mental model among the surgical team, reinforcing a spirit of teamwork and speaking up for safety concerns.  Operational differences aside, it is of the utmost importance to maintain consistent practice in accordance with nationally recognized surgical standards while recognizing that customization may be a helpful solution. This article describes the evolution of the SSC, obstetric considerations, and strategies for integration into practice. 

Historical development 

The first standardized team approach to support surgical safety and address the increased incidence of wrong-site, wrong-patient, and wrong-procedure events was launched by The Joint Commission in 2004 with the development of Universal Protocol. It includes 3 parts: a pre-procedure patient verification, site marking, and time-out. These were embodied into The Joint Commission National Patient Safety Goals in 2003 and 2004 (McLaughlin et al., 2012). 

The elements of Universal Protocol were later expanded upon in the development of the SSC, which was derived from another major advancement around this time- the WHO’s “Safe Surgery Saves Lives” initiative.  At this time, the WHO had been tasked with establishing global standards and guiding country-level development of patient safety protocols. Surgical safety was chosen due to data showing that surgical complications were a leading cause of death and disability globally, estimated at nearly seven million patients per year, with one million of these patients experiencing death (WHO, 2009). 

In 2007, a panel of experts convened in Geneva to address quality and safety concerns around preventable surgical harm and discuss potential solutions. Working groups were created to review available research, including studies in which nearly half of all surgical complications that resulted in patient injury or death were found to be potentially preventable (WHO, 2009). Also considered were increased reports of wrong-site or wrong-patient surgeries. The patient harm that drove this work stemmed from the following causes: improperly maintained equipment, inadequate surgical instrument training, miscommunication among teams, anesthesia-related injury due to unsafe or inconsistent practices (i.e.medication errors, airway mismanagement, hypoxia), surgical site infections, retained surgical items, and teamwork/communication breakdowns (McLaughlin et al., 2012; WHO, 2009). Obstetric patients were included in these reviews.

Among the scientific evidence reviewed was The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom- “Why Mothers Die 2000-2002”.  Maternal deaths due to Anesthesia complications- improperly placed tracheal tubes, disconnected oxygen supply, and inadequate Anesthesia supervision- were included (Lewis, 2004). From these and other reports came the WHO recommendations for standardization among Anesthesia equipment checks, continuous cardiac or pulse oximetry monitoring, and the presence of competently trained and continuously attended Anesthesia providers (WHO, 2009). 

WHO Guidelines for Safe Surgery 

As a result of this work, the Guidelines for Safe Surgery were created. A key component of this guideline was the SSC. Consistent findings noted in the literature reviews were directly translated into these documents, including Anesthesia machine and medication checks, and verification of the pulse oximeter to be both on the patient and functioning. The 19-item checklist, designed by Atul Guwande and other experts, involves 3 parts: before induction of anesthesia (including patient verification and site marking confirmation), before skin incision (time out), and before the team leaves the operating room.  Team checklist use promotes communication, standardization in care delivery, error mitigation, and psychological safety (WHO, 2009; Reinke et al., 2025). 

A multihospital global pilot study was implemented to evaluate the effectiveness of the Surgical Safety Checklist on patient outcomes and was published in the New England Journal of Medicine in 2009. Conducted in a prospective observational manner, the checklist was implemented at 8 hospitals within the WHO regions, after initial education and training were provided to operating room staff. Data was collected on 3955 patients after the checklist was implemented. Pre versus postimplementation results were remarkable: a 36% decline in the rate of inpatient postoperative complications, a 47% decrease in surgical mortality, a 45% decrease in surgical site infections, and a 25% decrease in unplanned returns to the OR (Haynes et al., 2009).  Since this time, many other hospitals have reported positive outcomes after implementation of the checklist (McLaughlin et al., 2012).  

Cesarean Section 

Cesarean delivery remains the most commonly performed major surgical procedure in the United States (Robinson et al., 2024). While it may be unlikely to have a wrong-patient or wrong procedure event in a cesarean delivery, unlikely does not eliminate all risk, especially given the variation in settings and concomitant procedures that may be occurring. The SSC also covers may other areas of surgical safety that are critical for patients. 

Consider the following scenario, which took place in Texas: 

A patient was admitted for a scheduled routine cesarean delivery in which a tubal ligation was performed without her knowledge or consent. Findings included a failure to perform a proper surgical time-out, including stopping to confirm the planned procedure with the patient and the consent forms, which resulted in this unauthorized procedure. (Walker v. Srivastava, 2011). 

Another consideration is that many clinicians (ie, residents, Attendings, scrub techs, midlevels, Anesthesiologists) often work in procedural areas throughout the hospital. Standardization across all areas is imperative in patient safety and achieving consistent outcomes. In other words, one cannot pick and choose where and how we implement the SSC; this would create variation in practice and a greater likelihood of errors. 

Factors that create a lack of buy-in are multifactorial and may include: 

• Rare frequency of serious safety events

• Production pressures creating a hurried approach 

• Staff turnover and the need for integration into onboarding curriculum

• Checklist overload- Checklists that become too long because they are continuously updated to include new safety event issues experienced as “one-offs” and not relevant to the majority of cases (Reinke et al., 2025). 

  
  

Tips for surgical safety checklist implementation

Patel and colleagues (2024), who describe developing a customized cesarean delivery SSC noted successful integration into practice.  This involved the following key steps: 

• Going to the people who do the work: bringing together a group of multidisciplinary key stakeholders, including frontline staff  

• Building it from the ground up: adjusting the checklist to include the specialties and issues unique to cesarean delivery

• Studying and adjusting to get it right: testing the checklist and making adjustments based on staff feedback

Other successful strategies: 

• Integrating a safety statement: encourages speaking up for safety concerns and promotes psychological safety: If anyone has a safety concern, I expect you to speak up

  • It’s incredibly powerful when stated by the Attending physician 

• Correctly using the checklist- reviewing each item with the checklist in hand (or electronically viewed), with verbal confirmation 

• Integrating into new hire onboarding of the why and how for sustainability 

• Using data to drive change: to track compliance- ie, audits to observe SSC being done correctly 

• Sharing data regularly with staff - on the units, in newsletters, at business meetings, and at staff meetings

References:

Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., & Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491–499. https://doi.org/10.1056/NEJMoa0805019 

Lewis, G. (Ed.). (2004). Why mothers die 2000–2002: The sixth report of the confidential enquiries into maternal deaths in the United Kingdom. RCOG Press. https://psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency 

McLaughlin, N., Winograd, D., Chung, H. R., Van de Wiele, B., & Martin, N. A. (2012). University of California, Los Angeles, surgical time-out process: Evolution, challenges, and future perspective. Neurosurgical Focus, 33(5), Article E5. https://doi.org/10.3171/2012.9.FOCUS12270 

Patel, V. J., Napolitano, G. P., Hemman, E. A., Nielsen, P. E., & Deering, S. (2024). Adaptation of the World Health Organization (WHO) Safe Surgery Checklist for use with cesarean sections: Implementation and outcomes with the Safe Cesarean Section Checklist. Cureus, 16(6), Article e61330. https://doi.org/10.7759/cureus.61330 

Reinke, C. E., Neff, L. P., & Talbott, A. L. (2025). Avoiding extinction: The importance of safety and timeouts in the OR. Surgery, 187(5), 109615. https://doi.org/10.1016/j.surg.2025.109615 

Robinson, S., Royer, H., & Silver, D. (2024). Geographic variation in Cesarean sections in the United States: Trends, correlates, and other interesting facts. Journal of Labor Economics, 42(Suppl 1), S219–S259. https://doi.org/10.1086/728804 

The Joint Commission. (2025). The Joint Commission sentinel event data 2024 annual review. https://digitalassets.jointcommission.org/api/public/content/eac7511986c0442a9c1ae04b1aa02cc0?v=ad34daa0 

Walker v. Srivastava, No. 2011-37055 (151st Dist. Ct., Harris County, Tex. 2011). 

World Health Organization. (2009). WHO guidelines for safe surgery 2009: Safe surgery saves lives. https://iris.who.int/server/api/core/bitstreams/c2ea24bb-10f7-48e4-8f63-55932e817ddc/content

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About the Author

Jeanette Zocco, MSN, RNC-OB, C-EFM, C-ONQS, is a leader in perinatal quality and safety with 28 years of experience in obstetrics. She has served as a bedside nurse, charge nurse, clinical nurse leader, perinatal safety nurse, and quality improvement specialist. Currently, she is a perinatal patient safety program manager, supporting quality and safety work for a multi-hospital healthcare system. Jeanette is recognized for developing innovative perinatal quality and safety programs in collaboration with multidisciplinary teams.

Copyright by Jeanette Zocco MSN RNC-OB, C-EFM, C-ONQS