Technique

Surgical checklists work. Here's how to build your own.

Omar Samara, MD · 2026-10-05 · 5 min read

You already run someone else's checklist. The time-out belongs to the room, and most of it is not about you.

This is about the other one. Five lines, yours, run before you scrub.

The famous numbers are real

Eight hospitals across eight cities introduced a 19-item surgical safety checklist and compared 3,733 patients before with 3,955 after. Deaths fell from 1.5% to 0.8%. Inpatient complications fell from 11.0% to 7.0%.

A Dutch group then tested a checklist covering the whole surgical pathway rather than just the operating room, in six hospitals, against five control hospitals. Complications per 100 patients fell from 27.3 to 16.7. In-hospital deaths fell from 1.5% to 0.8%. The control hospitals did not change.

And in a randomised trial in Norway, rolled out in random order across five surgical specialties, complications fell from 19.9% to 11.5%.

And then the study nobody quotes at conferences

Ontario told every hospital in the province to adopt a surgical checklist. That created a natural experiment across 101 hospitals, comparing 109,341 procedures before with 106,370 after.

Mortality went from 0.71% to 0.65%. Not significant. Complications went from 3.86% to 3.82%. Also not significant. Nothing happened.

The two sets of results are not actually in conflict. In the successful studies, somebody built the thing, taught it, and watched it being used. In Ontario, hospitals were told to have one.

That is the whole lesson for your own list, and it is worth saying plainly: a checklist you tick without reading is a piece of paper. The benefit comes from the thirty seconds of attention, not from the existence of the list.

Where checklists earn the most

The sharpest result is not from routine cases at all.

Seventeen operating-room teams ran 106 simulated crises — the cardiac arrests and massive haemorrhages that are common in a hospital and rare for any one person. Each team managed half the scenarios with crisis checklists and half from memory.

Missed lifesaving steps: 6% with the checklist, 23% from memory. Every single team performed better with the checklist than without.

Memory is worst exactly where the stakes are highest: rare, high-pressure, sequence-dependent. That is the shape of the thing worth writing down.

Two designs, and you need both

The checklist literature splits them cleanly.

• Do-verify. You work from knowledge and habit, then stop and confirm the list. Good for the things you do every week.
• Read-do. You read each item and do it as you read. Good for the rare setup you get wrong every time because you only meet it twice a year.

Most of your pre-case list should be do-verify. The one unusual positioning or the rare implant system deserves its own read-do card.

How to build yours

There is a published life cycle for medical checklists — conception, content and design, testing, training, then ongoing revision and retirement. The same paper is blunt that badly designed checklists produce "checklist fatigue" and get abandoned. So build it like it is a product you have to keep.

1. Pick one pause point. Before you scrub is the usual one. One list, one moment. Not three.
2. Cap it at five to nine items. If it does not fit on your phone's screen without scrolling, it is too long.
3. Earn every line. An item belongs there only if you have got it wrong before, or getting it wrong is expensive to fix later.
4. Mine your own notes. Go back through your last ten cases and pull the repeats. This is what the four lines you write after each case were for.
5. Write checks, not chores. "Implant sizes confirmed in the room" is a check. "Set up the room" is a chore.
6. Add the attending-specific line. Whatever this particular surgeon always asks for and you always forget. The preference card builder is a reasonable place to keep those.
7. Run it for two weeks, then prune. Any item that has never once caught anything comes off. A list that never catches anything stops being read.
8. Do not rebuild the time-out. Site, side, consent and antibiotics belong to the team's checklist. Yours is about your preparation, not the room's safety.

What mine tends to look like

A workable list is boring and specific. Something like:

• Images up on the screen and the side confirmed against them.
• Implants and sizes actually in the room, not "on the shelf".
• Positioning and bump agreed before drapes.
• The step I am asking to do today, said out loud to the attending.
• The one thing I got wrong in this case last time.

Five lines. Thirty seconds. That last item is the one that changes your rate of improvement, and it is the only one nobody else can write for you.

Keep it where you will actually meet it — on the procedure itself, next to the notes from last time, so it opens when you open the case.