A Multinational Audit of WHO Surgical Safety Checklist Adherence in Low-Resource Settings

Background: The World Health Organization Surgical Safety Checklist (WHO SSC) is a widely implemented intervention to improve perioperative safety. However, the extent to which these findings can be extrapolated to the real-world context is uncertain, particularly in low and middle-income countries (LMICs). The objective of this study was to evaluate the adherence to checklists, identify any implementation gaps, and assess the association between checklist adherence and perceived adverse event prevention across a range of healthcare settings. Methods: A prospective multicenter observational audit was conducted across seven countries within The Operating Room Global (TORG). The study incorporated both direct observation and retrospective review of surgical procedures. Ethical approval was obtained from The Operating Room Global Institutional Review Board (TORG-IRB), approval number TORG/IRB/002/2025 and local institutions. The analysis encompassed a total of 1,132 surgical procedures. The degree to which checklist adherence was demonstrated was evaluated at the overall, phase, and item levels. The primary outcome was a self-reported measure of perceived adverse event prevention, based on intraoperative team reporting, and does not represent objectively verified clinical outcomes. The associations were evaluated using bivariate analysis and multivariable logistic regression, with mixed-effects modelling to account for hospital-level clustering. A qualitative analysis was also conducted on the implementation barriers that were encountered. Results: Perceived adverse event prevention was reported in 77.1% of cases. Perfect checklist adherence was observed in 4.1% of cases and was associated with higher odds of perceived adverse event prevention in multivariable analysis (odds ratio [OR]: 6.40; 95% confidence interval [CI]: 1.91-39.9; p < 0.001), although the wide confidence interval suggests limited precision. However, this association was attenuated and no longer statistically significant after accounting for hospital-level clustering (OR: 3.45; p = 0.100; ICC = 0.27), indicating substantial variability between hospitals. Adherence to the checklist varied across the phases of the study, with substantial gaps in key safety items such as infection risk assessment (72.9%) and DVT prophylaxis (66.8%). The discriminative ability of checklist adherence was modest (AUC = 0.646). The qualitative findings identified training deficits and resource limitations as the primary barriers. Conclusions: While higher checklist adherence was associated with perceived adverse event prevention, this relationship appears to be strongly influenced by the institutional context. However, this association was not statistically significant after accounting for hospital-level clustering, suggesting that institutional and system-level factors may play a more critical role than adherence alone. Strengthening training, infrastructure, and workflow integration may support improved checklist implementation in low-resource settings. These findings should be interpreted in light of the subjective nature of the outcome measure. Keywords: Low-Resource Countries; Patient Safety; Surgical Safety Checklist; Global Surgery; Quality Improvement; Perioperative Safety