Systematic Review of Quality Improvement Interventions on Surgical Safety Checklists

Abstract

Introduction: Postoperative mortality is a significant global burden, partially driven by preventable perioperative errors, caused by human factors that contribute to preventable harm. The World Health Organization’s Surgical Safety Checklist (SSC) was introduced to reduce preventable harm during surgery and to improve surgical outcomes. Despite it being implemented across many healthcare systems, compliance and effective use of the SSC remains inconsistent. This systematic review aims to synthesize recent evidence on quality improvement interventions (QII) that target SSC implementation, identify strategies, and evaluate their impact on checklist utilization and related outcomes.

Methods: This systematic review was conducted in accordance with the Cochrane Handbook and reported following the PRISMA 2020 guidelines. A literature search was performed using MEDLINE and PsycInfo, which limited the studies to those published between 2015 and 2025. Data was extracted using a standardized form, and study quality was assessed using the Joanna Briggs Institute (JBI) Checklist for Qualitative Research.

Results: 23 studies published between 2015 and 2025 were included in this systematic review. The studies varied in design, sample size, units of analysis, and were conducted across a broad range of surgical specialties. QII included educational and training initiatives, audit and feedback mechanisms, mentorship programs, simulation-based interventions, and the introduction of modified checklist tools. Most interventions targeted all three phases of the SSC. Improved checklist compliance was the most frequently reported outcome. Fewer studies evaluated patient-centered outcomes.

Discussion: The findings indicate that QII are generally effective in improving implementation and the use of the SSC across diverse surgical settings. However, the evidence base is limited by heterogeneity in intervention types, outcome measures, and study designs, with most studies relying on observational or pre-post methodologies. The limited reporting of patient-level outcomes restricts conclusions regarding the direct impact of these interventions on postoperative morbidity and mortality.

Conclusion: Quality improvement interventions are associated with improved implementation and use of the SSC across diverse surgical contexts. While these interventions consistently enhance compliance and team engagement, further high-quality research is needed to determine its impact on patient outcomes and to identify the most effective and sustainable strategies.