Implementation of the WHO Surgical Safety Checklist and Its Role in the Perioperative Care Process and Postoperative Outcomes: A Prospective Longitudinal Study from a Tertiary Care Institute in Manipur, India

Abstract

Background: The WHO Surgical Safety Checklist (SSC) reduces perioperative morbidity and mortality, but its benefit depends on implementation quality. Northeast Indian data are scarce. Aim: To study WHO SSC implementation and its role in the perioperative care process and postoperative outcomes in a tertiary care institute in Manipur. Methods: This prospective longitudinal study included 224 patients undergoing elective or emergency general surgery at JNIMS, Imphal, from March 2024 to February 2026. Implementation was graded as complete (all three phases) or partial. Patients were followed until postoperative day 30; complications were graded by Clavien-Dindo classification. Results: Mean age was 40.0 ± 21.2 years; 60.3% were male; 59.8% of procedures were elective. All three checklist phases were completed in 14.3%, two phases in 17.4% and one phase in 68.3%. Antibiotic prophylaxis and normothermia were universal; site marking was performed in 44.6%. Complications occurred in 20.1%, surgical site infection in 14.3%, 30-day readmission in 9.4% and mortality in 1.8%. Compared with single-phase use, complete implementation was associated with shorter hospital stay (6.2 ± 2.4 vs 10.4 ± 10.5 days, p<0.001), fewer ICU admissions (6.3% vs 20.3%, p=0.003), fewer complications (9.4% vs 23.5%, p=0.001) and fewer readmissions (3.1% vs 11.8%, p=0.024), with no deaths. Complete implementation was lower in emergency than elective surgery (4.4% vs 20.9%, p<0.001) and rose from 7.1% to 21.4% during the study (p<0.001). Conclusion: Complete SSC implementation was infrequent but was associated with graded reductions in adverse postoperative outcomes, supporting efforts to achieve full adherence, particularly in emergency surgery.

Keywords: Checklist; Patient safety; Postoperative complications; Surgical wound infection; Emergency surgery; Quality improvement; World Health Organization