WHO Safer Surgery Checklist – Time-Out Procedure

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Source: Papadakis M, Meiwandi A, Grzybowski A. "The WHO safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety." International Journal of Surgery 69 (2019) 19–22.

1. Three Key Summaries

Abstract Summary

Catastrophic errors such as wrong-site surgery or retained items have devastating consequences. A brief, systematic time-out immediately before incision was introduced to prevent these "never events." Despite strong evidence of benefit, compliance remains a major problem, with gaps in routine practice.

Article Introduction Summary

The operating room blends complex technology with human teamwork, creating substantial risk. The Joint Commission’s Universal Protocol (2003) and the WHO Safe Surgery Checklist (2008) both formalized the time-out. Professional societies and risk management programs reinforced these steps as part of a broader "learning from errors" approach.

Conclusion Summary

The time-out remains a critical safety barrier and must be performed correctly to prevent wrong-site surgery and related harm. Yet compliance is still low, driven largely by limited awareness and inconsistent buy-in. Most successful strategies are educational and team-based.

2. How to Perform a Standard Time-Out

Definition

A time-out is the surgical team’s short pause just before incision to confirm they are about to perform the correct procedure on the correct body part of the correct patient.

Core Requirements

Element Details
Timing Immediately before incision (mean duration: 36 seconds)
Participants Every member of the surgical team must participate
Who initiates Any team member can call it; typically the circulating nurse or surgeon
Site marking Requires a marked operative site (but should still be done even if no site is marked)

The Three Phases of the WHO Checklist

  1. Sign-in briefing — performed preoperatively
  2. Time-out — performed just before incision
  3. Sign-out briefing — performed after skin closure but before patient enters post-anesthesia care

Core Time-Out Elements

  1. ✓ Correct patient identification (using ID band)
  2. ✓ Correct procedure verification (using informed consent)
  3. ✓ Correct site confirmation

Expanded Time-Out Elements

  • Surgeon identification
  • Patient’s position
  • Surgical items to be used/implanted
  • Medications/blood products to be delivered
  • Prophylactic antibiotics
  • Normothermia
  • Euglycemia
  • β-adrenergic blockade
  • Venous thromboembolism prophylaxis
  • Team member introduction
  • Safety statement by time-out leader
  • Review of critical imaging
  • Laser use (if applicable)

The Fail-Safe Procedure

  1. Circulating nurse holds patient’s ID band in one hand and informed consent in the other
  2. Nurse announces each verification item without interruption
  3. All surgical team members actively confirm each item
  4. Any discrepancy is resolved and corrected before proceeding
  5. Only when all agree → the operation starts

Special Situations

Situation Requirement
Multiple procedures by separate teams Distinct time-outs for each
Surgeon working in multiple ORs Must be present during each time-out
Discrepancy found Stop, investigate, correct before proceeding

3. Five Patterns of Incorrect Time-Outs

(a) Borderline

  • Description: Minor deviation from a full, acceptable time-out
  • Example: Circulating nurse performs time-out without cross-checking the patient’s identification band
  • Issue: Includes most key information but skips verification steps

(b) Related

  • Description: Verifies only patient name and operative site
  • Missing: No information about surgeon, position, and/or instrumentation/implants
  • Issue: Similar to borderline but omits multiple critical elements

(c) Contrary

  • Description: Performed passively or as a formality
  • Example: Nurse asks, "The patient is well-known to us, does everyone agree?"
  • Issue: Undermines the goal of active, systematic verification

(d) Invented

  • Description: Done only to satisfy documentation requirements
  • Example: Time-out called when no one is paying attention
  • Issue: Treated as a checkbox instead of a patient-safety reset

(e) Illegitimate

  • Description: The worst case — no time-out is performed at all
  • Issue: Operation proceeds without any safety verification

4. The Problem of Poor Compliance

Key Statistics

Finding Source/Detail
5% familiarity Only 5% of Norwegian surgical teams familiar with the Universal Protocol
90%+ agreement Over 90% of staff agreed time-out can prevent wrong-site surgery
73% mean compliance Dutch multi-center study (1,232 procedures, 16 hospitals)
44% without attention Time-outs performed without the surgical team’s attention
56% incomplete team Time-outs performed with an incomplete team present
41% limited participation German study: time-outs performed only between anesthetist and surgeon
60% theoretical knowledge Only 60% know the WHO campaign’s theoretical framework

Main Barriers to Compliance

  1. Limited awareness of the time-out’s safety impact
  2. Time pressure from tight schedules
  3. Surgeon resistance focused on speed, especially when details are added
  4. Perception as bureaucracy rather than a safety check
  5. Introductions seen as unnecessary — being known is valued over knowing others

Compliance Variations

  • Lower in academic hospitals than teaching hospitals
  • No relationship to hospital size
  • Varies among individual hospitals (different organizational structures)
  • Negative relationship with patient age (lower compliance for older patients)

Root Cause Analysis

Time-out related issues are the most common root cause of adverse events, ranking above:

  • Structural/human factors or equipment issues (2nd place)
  • Lack of standardization of critical clinical processes (3rd place)

5. Strategies to Increase Compliance

Physical Reminders

  • Sterilized metal plates bearing "Time-out" placed in all instrument sets (Mount Carmel Health System, Ohio)
  • Serves as visual reminder before incision

Educational Interventions

  • Leadership training and teamwork training identified as improvement avenues
  • Educational interventions shown to significantly reduce improperly performed time-outs
  • Simulation-based learning programs improve recognition of time-out protocol
    • Particularly useful for high-risk invasive procedures outside operating room

Technology-Assisted Methods

  • Audio-delivered checklists — improves overall team involvement in the time-out
  • Electronic mediation — feasible and inexpensive (effect on wrong-site surgery still being evaluated)

Patient Involvement

  • Most patients express satisfaction with participation in time-out
  • Challenge: Only 29% remembered the pre-induction time-out and felt reassured; 65% could not remember it
  • Patient education is needed to make the process meaningful

Awareness Campaigns

  • AORN National "Time-out" Day — launched in 2004, held annually in June
  • Promotes Universal Protocol and encourages active patient participation
  • Gained extensive media publicity

6. Recent Updates (2019–2025)

Current State: Progress Has Stalled

Despite two decades of protocols, a 2025 systematic review and meta-analysis of 13 studies (17,867 participants) found the global compliance rate remains at 73%1 — unchanged from 2019 estimates. More concerning:

Phase Compliance Rate
Sign In 76%
Time Out 61% (lowest)
Sign Out 62%

Overall completeness reached only 51%, meaning fewer than half of procedures worldwide fully adhere to the checklist1.

Alarming Trend: Wrong Surgeries Up 26%

According to The Joint Commission’s 2023 Sentinel Event Data, reported wrong site, wrong procedure, wrong patient, and wrong implant surgeries increased 26% in 20232. Wrong surgery and retained foreign objects each represented 8% of the 1,411 sentinel events reported that year.

Most at-risk specialties:

  • Orthopedics (35.3% of claims)
  • Neurosurgery (22.1%)
  • Urology (8.8%)

New Strategies Emerging (2023–2025)

Multi-Tier Leadership Intervention

A 2025 Croatian study demonstrated dramatic improvement through staged interventions3:

Phase Compliance
Baseline 78.3%
After admin directive 86.3%
After leadership meetings 92.0%
After quality audit 94.7%

The three-tier approach:

  1. Administrative directive — Formal letter from hospital director mandating compliance
  2. Leadership engagement — Individual meetings with department heads and head nurses
  3. Quality audit review — Structured internal audit discussions with leadership

AI and Technology-Enhanced Time-Outs

Emerging research supports AI technologies to enhance surgical processes4:

  • AI-assisted verification — Automated cross-checking of patient data, procedure, and site
  • StartBox System — Mobile app + safety-engineered blade delivery kit + data reporting tool that improves team communication along the care continuum
  • Electronic mediation — Feasible and inexpensive, though effectiveness data remains limited

Educational Program Success

A 2025 Pakistan study showed educational interventions improved overall checklist compliance from 58.36% to 78.05% (p=0.015)5. A 2023 Ethiopian study found surgical safety checklist workshops improved compliance, but only in hospitals with prior experience — emphasizing the need for multifactorial interventions6.

Updated Barriers & Facilitators (2025 Evidence)

Factors Enhancing Compliance:

  • Prior checklist exposure
  • Formal training programs
  • Supportive management culture
  • Positive work environment
  • Regular monitoring with feedback mechanisms

Persistent Barriers:

  • Insufficient staffing
  • Excessive workloads
  • Weak audit systems
  • Resistance to organizational change
  • Rapid staff turnover
  • Unclear role responsibilities1

2024 AORN Guideline Update

AORN updated the Guideline for Team Communication in 20247, providing evidence-based recommendations for perioperative nurses. Key updates include:

  • A significant number of adverse events in the OR are caused by system factors and non-technical elements of surgery
  • Revised recommendation for staff training on hand-off protocols based on best practices
  • Emphasis on developing a culture of safety that integrates team training, standardized safety checklists, and systems promoting resilience

Recommendations for improving Time Out:

  1. Standardize the Time Out process (standardization improves effectiveness)
  2. Involve all members of the perioperative team
  3. Designate one team member to call for the Time Out
  4. Stop all unnecessary activities and conversations when Time Out is called
  5. Discuss any patient safety concerns during the Time Out

National Time Out Day marked its 20th anniversary on June 12, 2024.

Quick Reference: Correct Time-Out Checklist

□ All team members present and attentive
□ Patient identification band verified
□ Informed consent document in hand
□ Patient name confirmed
□ Procedure confirmed
□ Operative site confirmed and marked
□ Surgeon identified
□ Patient position verified
□ Instruments/implants reviewed
□ Medications/blood products noted
□ Prophylactic measures addressed (antibiotics, DVT, etc.)
□ All team members verbally agree
□ Any discrepancy → STOP and resolve before proceeding

Adapted from: Papadakis et al., International Journal of Surgery 69 (2019) 19–22

References

  1. Beyond compliance: examining the completeness and determinants of WHO surgical safety checklist — a systematic review and meta-analysis. BMC Health Services Research (April 2025). https://pmc.ncbi.nlm.nih.gov/articles/PMC11971763/ ↩ ↩2 ↩3

  2. Wrong Surgeries Up 26% in 2023. AORN Periop Today (2024). Association of periOperative Registered Nurses. https://www.aorn.org/article/wrong-surgeries-up-26–in-2023 ↩

  3. Interventions to Improve Compliance to Surgical Safety Checklist Use: Before-and-After Study at a Tertiary Public Hospital in Croatia. Healthcare (Basel) (August 2025). https://pmc.ncbi.nlm.nih.gov/articles/PMC12385942/ ↩

  4. Innovative Technology System to Prevent Wrong Site Surgery and Capture Near Misses: A Multi-Center Review. Patient Safety in Surgery (2020). https://pmc.ncbi.nlm.nih.gov/articles/PMC7644953/ ↩

  5. Compliance with World Health Organization Surgical Safety Checklist: A Clinical Audit. Pakistan Journal of Medical Sciences (2025). https://www.researchgate.net/publication/390976871_Compliance_with_World_Health_Organization_Surgical_Safety_Checklist_A_Clinical_Audit ↩

  6. Addressing knowledge gaps in Surgical Safety Checklist use: statistical process control analysis of a surgical quality improvement programme in Ethiopia. British Journal of Surgery (November 2023). https://academic.oup.com/bjs/article/110/11/1511/7238684 ↩

  7. Speth K. Guidelines in Practice: Team Communication. AORN Journal (2024). https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.14161 ↩

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