The document outlines the development and impact of the WHO Surgical Safety Checklist, highlighting its origin from Dr. Thom O'Neill and its significance in reducing medical errors and complications during surgeries. It emphasizes the reduction in mortality rates since its implementation, reporting a 47% decline in deaths and saving an estimated 9,000 lives in Ontario. The checklist addresses systemic issues in healthcare, complexity in processes, and the necessity for proper training and leadership in its application.

1. The
WHO Surgical
Safety Checklist
A brief history (with Lego)
built by
Dr Thom O'Neill
Raigmore Hospital
NHS Highland
Scotland

2. The Checklist

3. Atul Gawande

4. Why do people
die from simple
errors?

8. The Super-Specialist

10. No more
Masters

11. The Burden Of
Knowledge

12. Human
Fallibility

13. Ignorance

14. Ineptitude

15. How do we
reduce
harm?

16. The Checklist

17. Complexity
Theory

18. The Glasgow Subway:
Simple

19. The Early
London
Underground:
Complicated

20. Complex

21. Construction

22. The
Master Builder

24. Too much
for one
individual

27. Complicated

28. Aviation

29. Individual Skill

30. Complex

31. The Hudson River
Emergency

32. Article 126

33. Healthcare

34. Where to start?

36. Who should lead it?

41. Is the correct
site marked?
Initial barriers

42. Anaesthetic machine

43. Prophylaxis

44. Drugs checked?

45. Expected blood loss

47. Eight major cities

48. Large and small centres

49. 35% 47%
Complications Deaths

50. SURPASS Trial
47% reduction mortality

51. Checklist in 2008
Flat death rates pre-2008
0.06% fall in rates per year since
Est. 9000 lives saved

52. Ontario study
9% fall in deaths
(0.71% to 0.65%)
Design problems (20% ophth)
Government mandated
Measured at 3 months

53. Mandate without training

54. Medics

55. Central lines

56. Pre-hospital