Surgical safety checklists are only truly useful when you take the time to make them your own. Here's advice on how you can customize the World Health Organization's Surgical Safety Checklist template (www.who.int/patientsafety/safesurgery/en) to fit your facility. For example, if your center, like ours, has difficulty following SCIP measures related to deep venous thrombosis prevention, you'll want to incorporate administering antibiotics at the right time and maintaining normothermia into the checklist.

Trial and, if need be, trim it. Put your checklist through its paces to work out the bugs, which may require multiple trials. (After 3 trial runs, we finally settled on a final draft.) A few physician-champions worked with our initial checklist; at the same time we also promoted the checklist to the rest of the surgeons to get their feedback. After an initial 1-month trial we brought the checklist back for revisions. It was obvious that we tried to cover too many issues and worked very hard with surgical leaders to streamline the topics the document touched. Your staff should be able to work through the checkboxes in 60 to 90 seconds; if it takes any longer they may be hesitant to adopt it into their pre-op routines. Focus on important safety issues and try to make the topics on the checklist applicable to every operation across all specialties.

Educate staff and surgeons. Conduct early and continuous educational sessions if you want checklist usage to stick at the front line. During our rollout of pre-op briefings (see "Go Beyond Time Outs With Pre-Op Briefings," March, page 16), we realized how important staff and surgeon champions and constant education are in maintaining an initiative's momentum and keeping it visible and constantly in the forefront of employees' minds.

Involve nurses. It's vital that nursing is involved from the beginning in the development of the checklist. The culture in your ORs will determine how much of a leadership role nurses will need to take to get the idea rolling. In our case, nurses got the checklist into our ORs faster and could introduce it into all of the rooms whether the doctor wanted to participate or not. Keep in mind that while nurses can lead the charge, in the end employing checklists on a consistent basis requires everyone's involvement.

Make it user friendly. Keep your checklist concise. The WHO's template identifies 3 phases of an operation, each corresponding to a specific period in the normal flow of work: before the induction of anesthesia ("sign in"), before the incision of the skin ("time out") and before the patient leaves the operating room ("sign out"). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.

Ours, too, has 3 sections. The first section addresses SCIP measures and Joint Commission directives, the middle section pertains to the pre-op briefing or time out and the last section guides the post-op debriefing, which is when we discuss things that went well, things we need to work on, key concerns for the patient's recovery and any equipment issues we may have encountered.

Place hard copies of the checklists in each OR and also note the checklist topics on whiteboards next to each surgical table. Also color-code the various sections of your checklist to make it stand out in a stack of papers. The goal is to make the checklist as visible as possible in the OR so staff are constantly reminded to complete it before surgery begins.

Plan for pushback. We didn't obtain much initial buy-in from physicians or nurses in spite of all our educational efforts. The physicians told us that the checklist takes too much time to complete and that they didn't need to use the document because they've never experienced safety-related problems on their watch. Nurses, meanwhile, claimed the checklist added to their workload and the topics it covered were more for the surgeons to worry about.

Neither argument was acceptable to us, and shouldn't be for you. Ask your staff to focus on the team aspect of ensuring patient safety. Support the development of the checklist and help guide its implementation, but the real work of developing it should come from the frontline staff. The last thing you want is to foster the perception that the checklist is being imposed from above.