In January 2009, the New England Journal ofo Medicine oublished our study as a rapid-releaes article. Even before then, word began to leak out as we distributed the findings to our pilot sites. Hospitals in Washington State learned of Seattle's results and began trying the checklist themselves. Pretty soon they'd formed a coalition with the state's insurers. Boeing, and the governor to systematically introduce the checklist across the state and track detailed data. In Great Britain, Lord Darzi, the chairman of surgery at St. Mary's hospital, had meanwhile been made a minister of health. When he and the country's top designate to WHO, Sir Liam Donaldson (who had also pushed for the surgery project in the first place), saw the study results, they launched a campaign to implement the checklist nationwide.

The reaction of surgeons was more mixed. Even if using the checklist didn't take the time many feared--indeed, in several hospitals teams reported that it saved them time--some objected that the study had not clearly established how the checklist was producing such dramatic results. This was true. In our eight hospitals, we saw improvements in administering antibiotics to reduce infections, in use of oxygen monitoring during operations, in making sure teams had the right patient and right procedure before making an incision. But these particular improvements could not explain why unrelated complications like bleeding fell, for example. We surmised that improoved communication was the key. Sport surveys of random staff members coming out of surgery after the checklist was in effect did indeed report a significant increase in the level of communication. There was also a notable correlation teamwork scores and results for patients --

the greater the improvement in teamwork, the greater the drop in complications.

Perhaps the most revealing information, however, was simply what the staff told us. More than 250 staff members -- surgeons, anesthesiologists, nurses, and others -- filled out ini an anonymous survey after three months of using the checklist. In the beginning, most had been skeptical. But by the end, 80 percent reported that the checklist was easy to use, did not take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room.

Nonetheless, someo skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care.

Then we asked the staff one more question. "If you were having an operation," we asked, "would you want the checklist to be used?"