Implementation of WHO Surgical Safety Checklist at Secondary Hospitals in Borno State: Challenges and Progress

The WHO Surgical Safety Checklist has been shown to reduce intraoperative complications and mortality, yet its consistent implementation in conflict-affected and resource-poor regions of Nigeria presents unique challenges. This study evaluates the status of WHO Surgical Safety Checklist implementation at secondary hospitals in Borno State, North East Nigeria, in 2023. A facility-based assessment was conducted at eight secondary hospitals using observation of 12 surgical procedures per facility and structured interviews with theatre personnel and hospital administrators. Checklist availability, staff knowledge, frequency of use, and perceived institutional barriers were assessed. Checklists were available in six of eight hospitals, but were consistently completed in only three facilities. The sign-out component was the most frequently omitted. Physician resistance, inadequate training, and high patient volume in emergency settings were the principal barriers. Hospital administrators at four sites were unaware that checklist use was a Ministry of Health requirement. The study recommends government-mandated checklist training, inclusion of checklist adherence in hospital accreditation criteria, and dedicated theatre quality improvement officers at each facility. Contextualizing checklist implementation for conflict-affected settings through simplified formats and mobile device applications is also advised for Borno State. Keywords: WHO checklist, surgical safety, Borno State, implementation, theatre safety