Surgical safety policies and procedures needed some adaptation during the COVID-19 pandemic. Some of those modifications may carry on in practice well after the pandemic ends.

Consider the World Health Organization (WHO) surgical safety checklist, which has helped professionals prevent errors, injuries, and deaths since its creation in 2009. Recently, a panel of researchers published a paper with updates for the WHO list, recommendations to guide surgeons into a new era, to help them improve safety during this pandemic — and possibly future, similar emergencies.1

“We’re working with the WHO and will, hopefully, be engaging with them when the 2009 checklist is updated,” says Mary Brindle, MD, MPH, paper co-author and director of the Safe Surgery/Safe Systems program at Ariadne Labs.

The WHO checklist started with 19 items, a simple, one-page document that could improve surgical team communication and care consistency. It was studied in eight cities globally. Before implementing checklist recommendations, data from 3,733 surgical patients showed a death rate of 1.5%. After surgeons adopted the recommendations, the rate declined to 0.8%. Inpatient complications declined from 11% to 7%.2

“The WHO checklist is a standard part of surgical procedures in operating rooms,” Brindle says. “In Canada, it’s a requirement for centers to use the checklist.”

The tool lists recommendations in three columns: Before induction of anesthesia, before skin incision, and before patient leaves operating room.3 The first column lists questions such as “Is the site marked?” The second and third columns include action items, such as this one in the “before skin incision” column: “Confirm the patient’s name, procedure, and where the incision will be made.”

The paper by Brindle and colleagues is an update on these procedures for the 2020s. They provided eight consensus recommendations for modifications to content and seven recommendations for handling the implementation.

“We have this pre-existing tool that can be adapted to address the issues around airborne infection prevention,” Brindle says. “Especially in places where the vaccine will not come anytime soon, we can use this tool to protect patients and surgical team members. The [new] recommendations are what we would add to the checklist and what we would change in terms of content and how to use the checklist. During a pandemic, one of the things you should be thinking about is making sure people in a surgical team understand the things that are important in protecting patients and team members.”

What follows are some sample items from the recent consensus recommendations:

Review patient’s COVID-19 test results, symptoms, and risk factors. “If a patient has high risk for COVID or has a COVID-positive test, how likely is it this patient could be a risk to the team members, and should the patient have surgery today?” Brindle asks.

Review the plan for intubation. When patients need a tube to help them breathe during surgery, there is potential for coughing and materials blocking their airway, which could be spewed into the field.

Surgery centers need their safety plans to include actions to take in the event a patient has COVID-19 or is at risk for contracting the disease. The plan might include making sure there are no extra staff in the operating room during intubation.

“Make sure people understand for each case they’re doing what that risk is to them and what they should do in their practice to protect themselves from their patients,” Brindle suggests. “We tried to not be too prescriptive, saying, ‘You need to do all of these things.’ Part of this paper is to allow people to feel like the checklist will work for them, where they are, and these things can be tailored to a particular operating room or facility.”

Review aerosolization risks. “How likely is the patient to produce a lot of aerosols?” Brindle asks.

For instance, if the procedure moves through the patient’s nose to access the brain, then it would be much more likely to produce aerosols than a procedure on the patient’s ingrown toenail. “The back of the nose is a place really high in COVID virus if the patient is positive,” Brindle notes. “The [brain] surgery may create a large amount of aerosol that could form clouds around the team.”

Ensure in-room availability of all necessary equipment. This recommendation is designed to minimize the number of times people enter or leave the operating room. “Part of what keeps people safe in the hospital is that the OR doors are closed,” Brindle says.

The goal during the pandemic is to reduce opportunities for aerosols to spread to and from the OR. “You also want to make sure you don’t have extra equipment in the room, where the virus gets on top of it, sitting on top of surfaces,” Brindle says. “Make sure [staff] don’t open the door and bring extra people in the room.”

Discuss handling, packaging, and transport of lab specimens. “This is one where we had a lot of discussion about it and how much risk there is for people touching specimens that have come from COVID patients,” Brindle says. “So much of what we know about the virus is evolving. If there is highly infected tissue, you would want to be more careful about it.”

Confirm postoperative bed availability. “Where does the patient go to recover, and what is their exposure to other patients?” Brindle asks. “If we take a tube out of your throat, you will cough a lot. Would you be in close proximity to other people and put them at risk?”

The surgery center or HOPD might mitigate this risk with good air exchange and ventilation. “Many places, even in hospitals with good air exchange, avoid putting the post-op patient with COVID in the same general post-op care units as other patients,” Brindle observes.

Sign out before extubation. “One of the high-risk periods for transmission is when the tube is being removed,” Brindle says.

To reduce risk, policies should direct staff to leave the room unless they are needed. Surgery leaders should engage in discussions about other plans that would lower risk at extubation. 


  1. Panda N, Etheridge JC, Singh T, et al. We asked the experts: The WHO surgical safety checklist and the COVID-19 pandemic: Recommendations for content and implementation adaptations. World J Surg 2021;45:1293-1296.
  2. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-499.
  3. World Health Organization. Surgical safety checklist. 2009.