WHO Surgical Safety Checklist: Questions Patients Can Borrow Before Surgery Abroad

What the checklist is

The World Health Organization published its Surgical Safety Checklist in 2009 as part of its "Safe Surgery Saves Lives" work. According to WHO's safe-surgery resources page, it is a 19-item tool meant to reduce errors and adverse events and to improve teamwork and communication in surgery. It's built around three pauses:

1. Before anesthesia begins (often called the "sign in")
2. Before the first incision (the "time out")
3. Before the patient leaves the operating room (the "sign out")

WHO encourages hospitals to adapt the checklist after local consultation. So the version used where you have surgery may look a little different from the original, and that's expected.

Why it gets so much attention

The checklist's reputation comes partly from a study in the New England Journal of Medicine (2009). Researchers introduced it in eight hospitals in eight cities, from Toronto and Seattle to New Delhi, Manila and Ifakara in Tanzania. Among patients aged 16 and older having noncardiac surgery, the death rate fell from 1.5% before the checklist to 0.8% after, and in-hospital complications fell from 11.0% to 7.0%.

Those results come from a before-and-after comparison in specific hospitals. They don't mean any clinic that "uses the checklist" will cut your personal risk by those amounts. The lesson is that structured pauses for communication can catch problems that busy teams otherwise miss.

What the three pauses typically cover

Local versions vary. A published implementation study in Patient Safety in Surgery (2014) sets out the items a hospital used. They give a good sense of what each pause involves.

Borrowing pause 1: Make sure everyone agrees on what's being done

The first pause exists because mix-ups in patient, procedure and site do happen. As a medical traveler, you can prevent the version of that problem that starts with unclear planning.

• Get the exact procedure in writing, including side and level where relevant. "Lipo package" or "dental makeover" isn't a procedure name.
• Make sure your consent form describes the same procedure as your quote and your conversations. If anything changed after your in-person consultation, see what informed consent should cover.
• Bring your allergy list and anesthesia history on paper. Expect to be asked again. Repeating it is part of the safety design, not a sign of disorganization.

Borrowing pause 2: Know the team and the plan

Introductions before the incision are about everyone knowing who is responsible for what. You can do your part before you travel.

• Ask who will be in the operating room. At minimum, know your surgeon and your anesthesia provider by name. Check them separately, as described in how to verify the anesthesia plan.
• Ask about preventive antibiotics. Ask whether they are planned for your procedure and when they would be given. Mention any antibiotic allergy.
• Ask how long the operation should take and what the critical steps are. A surgeon who can explain this simply has usually thought it through.
• Confirm your imaging has arrived if your surgery depends on it.

Borrowing pause 3: Plan the handover

The final pause makes sure nothing is left behind, specimens are labelled and recovery concerns are passed on. For you, it's a reminder that the paperwork from the operation matters.

• Ask whether any tissue will go to pathology, and how and when you'll receive the report.
• Ask for the operative report and discharge summary before you leave the country. The list of documents to collect is in what medical records to take home.
• Ask who is responsible for your recovery once you leave the operating room, and how to reach them after hours.

How to raise the checklist without micromanaging

You won't be running the checklist, and you'll be asleep for part of it. One or two calm questions during your consultation show what you need to know:

• "Does your operating team use a surgical safety checklist, such as the WHO checklist or a local version?"
• "Will I be asked to confirm my name, procedure and site before anesthesia?"
• "Is my site marked before I go into the operating room?"

A confident "yes" with a short explanation is a good sign. Surprise, irritation or "we don't need that here" is worth noticing.

Make your own one-page version

You can turn the three pauses into one sheet to bring to your pre-operative visit. Keep it short and factual:

When there's a language barrier

The checklist depends on clear spoken confirmation, and that works only if you understand the questions and the team understands your answers. If you don't speak the local language well, ask before you travel how confirmations before anesthesia will be handled. Find out whether a qualified interpreter will be present for that conversation, not just at your first consultation. Nodding along to a question you didn't fully understand defeats the purpose of the pause.

If you notice a mismatch

Patients sometimes notice something before anyone else does: the wrong side marked, a medication they're allergic to, a procedure name that doesn't match their consent. If that happens, say so clearly, before any sedation is given, and ask the team to pause until it's resolved. This is exactly what the pre-anesthesia confirmation is for. A professional team will welcome the correction. Once you're sedated, you can't catch anything, so the minutes before anesthesia are your best chance to speak up.

What a checklist can't do

A checklist is only as good as the culture using it. A form ticked by habit, with no real pause, gives little protection. A checklist also can't make up for a poorly chosen procedure, an unsuitable facility, inadequate anesthesia support or missing follow-up. Use it as one window into how a team works, alongside the other checks this site covers, including the questions to ask about complications before you travel.

Frequently asked questions

Do all hospitals abroad use the WHO Surgical Safety Checklist?

Not necessarily, and many use a locally adapted version, which WHO encourages. Ask your surgical team whether they use a structured checklist and whether you'll take part in the confirmation before anesthesia.

Can I ask to see the checklist?

You can ask whether one is used and what you'll be asked to confirm. Teams vary in whether they show the form itself. What matters more is that the pauses actually happen.

Why do staff keep asking my name and procedure?

Repeated confirmation of identity, procedure and site is deliberate. It's one of the main ways surgical teams prevent mix-ups. Answer fully each time, even if it feels repetitive.

Does using the checklist guarantee my surgery will be safe?

No. A large 2009 study linked the checklist to fewer deaths and complications in the hospitals studied, but no tool guarantees an individual outcome. It works alongside proper patient selection, a suitable facility and good follow-up.

What should I do if my procedure is described differently on the day?

Stop and ask before you agree to anything. If the procedure, side or plan differs from what you consented to, you're entitled to a clear explanation, and to time to decide.