Implementation of the WHO surgical safety checklist in resource-limited Somalia: a new standard in surgical safety

Abstract
Background Surgical safety remains a critical global health concern, with complications from surgical procedures
resulting in significant morbidity and mortality, particularly in low- and middle-income countries. The World Health
Organization (WHO) Surgical Safety Checklist (SSC) has been shown to reduce surgical complications and mortality
rates. However, its implementation and impact in resource-limited settings like Somalia remain understudied. This
study aimed to evaluate the implementation of the WHO SSC in selected hospitals in Mogadishu, Somalia, and assess
its impact on surgical safety practices.

Methods A pre- and post-intervention study was conducted in 15 randomly selected hospitals in Mogadishu,
Somalia. The intervention involved a comprehensive training program on the WHO SSC for surgical teams. Data on
hospital characteristics, surgical details, and adherence to the SSC were collected over two periods: pre-intervention
(April 12th to May 4th, 2024) and post-intervention (May 12th to June 3rd, 2024). The primary outcome was the
adherence to the SSC, categorized as good (>60%) or poor (≤60%). Descriptive statistics, McNemar’s test, and binary
logistic regression were used for data analysis.

Results Adherence to the WHO SSC significantly improved post-intervention, with 98.8% of surgical cases
demonstrating good adherence compared to 37% pre-intervention (p<0.001). The mean adherence score increased
from 51.6% (SD=29.6) to 94.1% (SD=8.2). Significant improvements were observed for most individual checklist
items, including patient identity confirmation, surgical site marking, anesthesia machine checks, and pulse oximeter
use (p<0.001). Team dynamics and communication also improved significantly post-intervention. Hospital type, size,
years of service, funding source, surgical department, surgery type, urgency, and staff numbers were associated with
checklist adherence pre-intervention

Conclusion The implementation of a comprehensive training intervention significantly improved adherence to
the WHO Surgical Safety Checklist in resource-limited hospitals in Mogadishu, Somalia. The findings highlight the
feasibility and effectiveness of the SSC in enhancing surgical safety practices, team communication, and patient