The Importance of Checklists in Anesthesia

May 6, 2020

Surgical checklists have grown in popularity over the past two decades as a means of streamlining procedures and avoiding damaging errors. A variety of studies in almost every specialty have shown that checklists reduce risks associated with surgery and prevent unnecessary deaths. As a result, in 2009, the World Health Organization recommended that checklists be included as a standard part of every surgical care procedure [1]. While the WHO checklist, which accompanied the recommendation, contains a few items for anesthesia, several studies have since offered more complex checklists geared specifically toward anesthesia providers.  

The surgical checklist is based on pilot’s pre-flight checklists, a series of standardized steps each pilot must perform before flying a plane. Much like a plane, surgery involves a series of complicated processes and coordinating the actions of a large team. Particularly in emergency situations, checklists are an aid to ensure that all necessary steps are fulfilled, avoiding infection or mistakes that come from misinformation or disorganized operations [2]. Indeed, an early study by Hart et al. used an electronic checklist device, like the ones used by pilots, in anesthesia trials. After the trial, 95% of participants reported finding the electronic checklist useful in their procedure [3]. 

Checklists are particularly popular in high-income countries, where the WHO checklist has been expanded for anesthesia-specific purposes. An anesthesia pre-induction checklist (APIC) is one such system that was designed to complement the WHO preoperative checklist. In a study by Tscholl et al, 105 anesthesia teams were given an APIC to use in the preoperative process. Those who used the APIC—88% of teams—had increased information exchange, better knowledge of critical information, and improved perceptions of teamwork. Anecdotally, teams in the control group experienced two critical mishaps, while those using the APIC had no medical errors [4].  

During the postoperative period, a checklist is important in ensuring a smooth handoff. A study by Robins and Dai found that the use of a postoperative checklist increased handoff adequacy from 14% to 100%. Likewise, the postoperative process often involves frequent calls back to the operating team to clarify information regarding the patient and the procedure. However, those using the checklist never had to clarify information, compared to 69% of teams in the control group [5]. Use of a checklist therefore ensured that members of the operating team transmitted relevant information to the postoperative team. 

In low-income countries, checklists have improved quality of care and reduced the risk of infection and mortality [6]. In fact, according to a study by Haynes et al, the implementation of the WHO checklist decreased deaths by 46%, with much of this decrease felt by low-income countries where mortality rates associated with surgery tend to be higher [7]. While prevailing attitudes held by some doctors in these regions have hindered checklist rollouts, the results have largely been successful. In Benin, an effort by a nonprofit to encourage checklist adoption raised the rate of checklist use at hospitals in the program from 30% to 90%. In a follow-up study by White et al, a year later, 86% of those hospitals were still using checklists [8]. 


[1] Borchard A, Schwappach DL, Barbir A, Bezzola P. A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg. 2012;256:925–33 

[2] Gawande, Atul. “A Life-Saving Checklist.” The New Yorker, The New Yorker, 19 June 2017, 

[3] Hart, Elaine M., and Harry Owen. “Errors and Omissions in Anesthesia: A Pilot Study Using a Pilot’s Checklist.” Anesthesia & Analgesia, vol. 101, no. 1, 2005, pp. 246–250., doi:10.1213/01.ane.0000156567.24800.0b. 

[4] Tscholl, David W., et al. “An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.” Anesthesia & Analgesia, vol. 121, no. 4, 2015, pp. 948–956., doi:10.1213/ane.0000000000000671. 

[5] Robins, Holly-May, and Feng Dai. “Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care.” AANA Journal, vol. 83, no. 4, Aug. 2015, pp. 264–268. 

[6] Mcneil, Donald G. “Where Surgeons Don’t Bother With Checklists.” The New York Times, The New York Times, 15 Jan. 2020, 

[7] Haynes, Alex B., et al. “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.” New England Journal of Medicine, vol. 360, no. 5, 2009, pp. 491–499., doi:10.1056/nejmsa0810119. 

[8] White, M. C., et al. “Implementation and Evaluation of Nationwide Scale‐up of the Surgical Safety Checklist.” Bjs, vol. 106, no. 2, 2019, doi:10.1002/bjs.11034.