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Volume 1 Supplement 1

Safety in Health

Leak in Surgical Safety Checklist?


Since the dawn of surgery patient safety has been a major issue. In 2008 the WHO Surgical Safety Checklist was developed after extensive consultation, aiming to decrease errors and adverse effects. The WHO Checklist is used originally or based on by a majority of surgical providers around the world - even with us. Nevertheless, mistakes happen.

Material and methods

We report a case that has taken place in our department, supplemented by literature review.

Modified WHO Safety Checklist has been used in our department since a couple of years ago. Although "Team Time Out" was performed standardly following unpleasant situation happened: after an elective arthroscopy, while the surgeon finished documentation, the responsible nurse informed him that the indicator strip for sterility did not show any discoloration.

No one of the operating room personal knew whether the indicator strip was not checked or if it had been overlooked although a modified WHO Surgical Safety Checklist was performed carefully.

Subsequently the question arose, what does it mean to the patient if surgical instruments were not sterilized but only cleaned by Washer-Disinfector.


The patient has not suffered any infection. Review of the literature has shown that the machine washer-disinfector consistently reduces microorganisms [1]. The risk of transmission of infection may be considered negligible [2].

Figure 1
figure 1

Indicator strip for sterility (black=sterility is given; white=sterility not given).


Despite the use of checklists, errors still happen. Everyone on the team is required not only to do their own part. Moreover, everyone is required to take care of "the whole big picture".


  1. Donskey C, Yowler M, Falck-Ytter Y, Kundrapu S, Saltata RA, Rutala WA: A case study of a real-time evaluation of the risk of disease transmission associated with a failure to follow recommended sterilization procedures. Antimicrob Resist Infect Control. 2014, 3 (1): 4-

    Article  PubMed  PubMed Central  Google Scholar 

  2. Rutala WA, Weber DJ: How to assess risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines. Infect Control Hosp Epidemiol. 2007, 28 (2): 146-155.

    Article  PubMed  Google Scholar 

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Correspondence to Renate Krassnig.

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There are no financial interests to declare.

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Fellacher, F.J., Walter, D., Aldrian, D. et al. Leak in Surgical Safety Checklist?. Saf Health 1 (Suppl 1), A18 (2015).

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