Dr. Atul Gawande: Surgical Safety and Analysing Surgical Errors

Every time a surgeon performs an operation, there are hundreds of steps that need to go exactly right. From correctly identifying the patient and preparing the surgical site, to administering anaesthesia, performing the procedure itself, and ensuring the wound is safely closed, the margin for error is incredibly small. Even the most skilled surgeons can make mistakes, which can lead to harmful risks if overlooked. In such high-stakes environments, these mistakes can lead to serious complications, prolonged recovery, and even death. The big question is, how could we reduce these risks?

This was what Dr. Atul Atmaram Gawande—a Harvard-trained endocrine and general surgeon, author, and public health researcher—set out to answer. In the early 2000s, Dr. Gawande began documenting how routine surgical procedures, even in the best hospitals, often led to preventable complications. These failures, he argued, were not usually from a lack of knowledge or skill, but rather of a flawed system. In his book Complications: A Surgeon's Notes on an Imperfect Science, he examines real cases of surgical error and the challenges physicians face when dealing with uncertainty and decision-making under pressure.

One of his biggest contributions to global medicine was the Surgical Safety Checklist, which he led the team in developing with the World Health Organisation (WHO). This 19-item checklist is designed to help surgical teams confirm critical safety steps in three main phases: before induction of anaesthesia, before skin incision, and before the patient leaves the operating room. These steps confirm important information like the patient's identity, the site of surgery, and any allergies or risks (such as blood loss and aspiration), verifying that all surgical instruments and sponges have been accounted for, and team discussions.

Dr. Gawande draws inspiration from industries such as aviation; In, The Checklist Manifesto, he quotes that multiple fields have “become too much airplane for one person to fly,” drawing an analogy to the B-17 Flying Fortress, a plane that crashed shortly after takeoff due to the pilots forgetting to disengage the gust locks. To avoid similar accidents in the future, AirCorps developed a checklist the crew must follow for takeoff, flight, and landing. To this day, this idea is still in use, allowing members of aircraft teams to work together efficiently. 

Implementing Dr. Gawande’s checklist, a 2009 study published by The New England Journal of Medicine evaluated 7,688 patients aged 16 and above across eight hospitals worldwide from both high and low income countries—3733 patients before and 3955 patients after the checklist was implemented. After introducing the checklist, the rate of surgical complications dropped from 11.0% to 7.0% and the rate of in-hospital deaths fell from 1.5% to 0.8%. All eight hospitals experienced similar results, despite being from different income levels.

Today, the WHO checklist is used in hospitals across more than 120 countries, and it has been integrated into national surgical policies in several countries. Beyond the checklist, Dr. Gawande has written on the importance of analysing surgical performance and encouraging open discussion of medical errors and improvement. He urges teams to engage in this process and improve decision-making by learning from the outcomes rather than by assigning blame.

Written by Shanisse Tan at Incisionary

APA References

Gawande, A. (2002). Complications: A surgeon’s notes on an imperfect science. Metropolitan Books. https://atulgawande.com/book/complications/

Gawande, A. (2009). The checklist manifesto: How to get things right. Metropolitan Books. https://atulgawande.com/book/the-checklist-manifesto/ 

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