Why Nigerian surgical teams struggle to complete the WHO safety checklist

A qualitative study of surgical team members at two Nigerian tertiary hospitals has identified the practical, human and organizational obstacles that prevent full use of the WHO Surgical Safety Checklist, a tool designed to make surgery safer by prompting teams to complete essential safety steps before, during and after each operation. The research, published in BMC Health Services Research, was led by Ajibola O. Omokanye and colleagues and is reported as an exploratory qualitative study conducted at Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) in Ile-Ife, Osun State, and Ekiti State University Teaching Hospital (EKSUTH) in Ekiti State.

The checklist, developed by the World Health Organization, is structured around three critical phases: “sign in” before anesthesia, “time out” before incision, and “sign out” before the patient leaves the operating room. Each phase is designed to ensure adherence to essential safety steps, improve communication among surgical teams, and reduce avoidable problems during surgery. Although evidence from around the world supports the checklist’s effectiveness, the study’s authors note that reported checklist use in low- and middle-income countries, including Nigeria, is consistently and substantially lower than in high-income settings.

To understand why, the researchers used a qualitative exploratory design and carried out key informant interviews with 13 participants, including consultants, resident physicians, nurses and anesthetists drawn from the two teaching hospitals. Data were collected with a semi-structured interview guide, transcribed verbatim and subjected to thematic analysis. Data collection continued until thematic saturation was reached, defined as the point at which no new themes or insights emerged from subsequent interviews.

Three main themes emerged from the analysis. The first was systemic and workflow constraints, including insufficient staffing, excessive workload, time pressure and emergencies. The second concerned human factors and team dynamics, such as poor cooperation, weak accountability and hierarchical barriers within surgical teams. The third theme covered training, awareness and attitudes, encompassing inadequate training, checklist fatigue, and the perception among some staff that the checklist is merely a box to be ticked rather than a meaningful safety instrument.

According to the study, these obstacles hindered the continuous and comprehensive utilization of the checklist in both institutions, with a more significant impact observed at EKSUTH. The findings also indicate varying levels of preparedness for checklist implementation across the two hospitals, particularly in terms of staffing, training and workflow integration. Both hospitals have adopted the checklist, but the authors conclude that systemic, behavioral and organizational hurdles make it difficult to apply the tool to its full potential.

The study is limited by its qualitative design and small participant pool of 13 interviewees at two hospitals, so the findings describe the experiences and perceptions of these surgical team members rather than measuring checklist compliance rates or patient outcomes. As an exploratory study, it identifies obstacles and themes as reported by participants; it does not test interventions or quantify the effect of any barrier on surgical safety.

Nevertheless, the authors draw practical conclusions for hospital leadership. To improve the culture of safety in Nigerian tertiary hospitals, they argue, leaders need to be committed, personnel need to be trained, workflow support must be improved, and positive safety norms need to be reinforced. They also suggest that adapting the checklist to local workflows, rather than relying solely on the generic WHO format, may further improve adherence and sustainability.

The research adds to a broader body of evidence that the Surgical Safety Checklist’s three-phase structure — sign in, time out and sign out — depends not only on the tool itself but on the staffing levels, team dynamics and training culture of the institutions that implement it. For the two Nigerian tertiary hospitals studied, the path to more complete checklist use, as described by the participants, runs through better staffing, stronger accountability across professional hierarchies, and training that addresses checklist fatigue and the perception that the checklist is a formality.

Because the interviews captured the perspectives of consultants, resident physicians, nurses and anesthetists at both institutions, the study offers a multi-professional view of where the checklist breaks down in daily practice. The authors’ recommendation to adapt the checklist to local workflows, alongside leadership commitment and improved workflow support, reflects the central finding of the research: both hospitals have adopted the checklist, but systemic, behavioral and organizational hurdles currently prevent it from being applied to its full potential.

Subject of Research: Barriers to compliance with the WHO Surgical Safety Checklist in two Nigerian tertiary hospitals

Article Title: Obstacles to compliance with the surgical safety checklist in two nigerian tertiary hospitals: An exploratory qualitative study

Article References: Omokanye, A. O., Ojo, I. O., Oyediran, O. O., Abiodun, T., Ojo, E. A., Abdur-Rahman, A. B., Adeagbo, A. O., Badedale, M. E., Khadijah, J., & Ademuyiwa, I. Y. (2026). Obstacles to compliance with the surgical safety checklist in two nigerian tertiary hospitals: An exploratory qualitative study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15902-3

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15902-3

Keywords: surgical safety checklist, WHO, Nigeria, tertiary hospitals, qualitative study, patient safety, operating room, team dynamics, health workforce, LMICs, thematic analysis, surgical teams