Surgery plays a vital role in public health, with its importance steadily increasing over the past century
[1]
. However, surgical procedures can pose significant risks, including adverse events (AEs) and even death, nearly half of which are considered preventable
[1]
. To mitigate these risks, the World Health Organization introduced the Surgical Safety Checklist (SSCL), which has been shown to reduce complications and improve patient outcomes
[1]
-
[5]
.
Despite widespread adoption in high-income countries, SSCL implementation in low- and middle-income countries (LMICs) remains inconsistent
[6]
, with reported usage rates ranging from 39.7% to 100% and generally low fidelity to checklist components
[7]
-
[9]
. Even when SSCLs are employed, completeness across the three checklist phases—sign-in, time-out, and sign-out—is often suboptimal and rarely exceeds 60%
[9]
. Implementation barriers in LMICs include insufficient training, high workload, and poor team coordination
[9]
[10]
. Moreover, some studies suggest the SSCL primarily benefits those areas it specifically targets
[11]
.
In Cameroon, available data on SSCL use are limited to major urban centers like Douala and Yaoundé, with little known about its application in rural or northern regions
[12]
. To address this gap, our study evaluated SSCL compliance (penetration) and adherence (fidelity) in obstetric and gynecologic surgeries in Northern Cameroon. We hypothesize that SSCL use remains low in Northern Cameroon, and where used, adherence is below the standard recommended guidelines. By identifying local barriers and performance gaps, our study aimed to support the development of strategies for nationwide implementation.
2. Methods2.1. Study Design and Setting
This prospective observational study was conducted over six months in four hospitals located in Garoua, Northern Cameroon: Garoua Military Hospital (GMH), Garoua Regional Hospital (GRH), Garoua General Hospital (GGH), and the Regional Hospital Centre (RHCG). These facilities were selected based on their involvement in surgical care and high patient turnover. GMH and GRH function as secondary-level referral hospitals, while GGH and RHCG serve as tertiary centers. All participating hospitals had functional obstetric and gynecologic units, operating theaters, and intensive care units. However, staffing was limited, with only one or two gynecologists/obstetricians per hospital and a shortage of theater nurses and support personnel.
Two of the hospitals (RHCG and GRH) had French-translated World Health Organization (WHO) Surgical Safety Checklists (SSCLs) and written surgical safety protocols available in the operating theaters. In tertiary centers, gynecological procedures were performed exclusively by specialists. In contrast, emergency cesarean sections in secondary-level hospitals were sometimes performed by general practitioners or surgeons in the absence of obstetricians. The SSCL was used only for procedures performed in the main operating theaters under regional or general anesthesia.
2.2. Sample Size Justification
This study did not use a formal power calculation, as it was exploratory in nature. The aim was to obtain a representative understanding of SSCL utilization and adherence patterns in the region. Therefore, a consecutive sampling approach was employed, including all eligible surgical cases observed during the study period. While not a pilot study per se, the findings are intended to guide future larger-scale studies and policy interventions.
2.3. Sampling and Observer Assignment
Consecutive sampling was used to include all eligible surgical cases during which a trained observer was present. To minimize selection bias and ensure temporal representativeness, trained senior medical students were scheduled to cover all surgical shifts—day and night, weekdays and weekends—via a structured duty roster. Emergency surgeries without observer presence were excluded from the analysis to maintain data consistency. The principal investigator conducted regular oversight through weekly site visits (3 - 4 days per week) and routine phone follow-ups with observers.
2.4. Inclusion and Exclusion Criteria
Women undergoing gynecological or obstetric surgeries during the study period with a designated observer present were included in the study.
We excluded emergency surgeries performed without observer presence.
A second study phase involved purposive sampling of surgical team members for interviews to identify barriers to SSCL compliance.
2.5. Operational Definitions2.6. Data Collection Procedure
A structured data collection sheet was developed based on the WHO SSCL implementation framework and adapted to the local context. It was pilot-tested in a non-participating hospital over one week for clarity, usability, and comprehensiveness. Feedback from this pilot phase was used to refine the tool before full deployment. While formal psychometric validation was not conducted, face and content validity were established through expert review by local clinicians and researchers. A copy of the final data collection tool is provided as Supplement. This sheet was used to collect the information in patient records including age, surgical indication, type of surgery (elective or emergency), surgeon’s qualification, and SSCL availability. The checklist forms were reviewed on the following aspects: use of the SSCL (penetration) and the completeness of each of its three sections (fidelity).
Regarding staff interviews, demographic data (age, years of experience), prior training on patient safety, and self-reported reasons for partial or non-use of the checklist were recorded.
2.7. Data Management and Analysis
Data were cleaned, verified for accuracy, and recorded in Microsoft Excel before being exported to IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY) for analysis. Descriptive statistics, including frequencies, means, and percentages, were used to summarize the data. Associations between categorical variables were assessed using Chi-square tests. Statistical significance was set at p < 0.05, with 95% confidence intervals reported where appropriate.
2.8. Ethical Considerations
Ethical clearance was obtained from the Institutional Review Board of the Faculty of Health Sciences, University of Buea (Ref: 2023/1930-01/UB/SG/IRB/FHS; dated 02/02/2023). Additional administrative authorization was secured from all participating hospitals. Informed written consent was obtained from all surgical staff who participated in the interview phase of the study.
3. Results
Three hundred and six gynaecological and obstetrical surgeries were performed during the study period but 16 of them could not be observed by an investigator. We finally enrolled 290 procedures into the study distributed as indicated in
Figure 1
below. The majority of cases were recruited in GRH (73.79%) and the least at the RHCG (5.18%).
3.1. Descriptive Results
Table 1
below displays the general characteristics of patients, surgical indications and health workers. Over 62% of surgeries were done as emergencies. Caesarean section contributed to more than 68% of the indications followed by myomectomy through laparotomy 25 (8.62%). The procedure was carried out by an obstetrician-gynaecologist in only 65% of cases.
Figure 1. Distribution of participants in study sites.
<xref ref-type="bibr" rid="scirp.144020-"></xref>Table 1. General characteristics of patients, surgical indications and health workers.
Variables
Frequency
Percentage (%)
Type of surgery
Emergency
182
62.76
planned
108
37.24
Surgical indications
Caesarean section
198
68.28
Myomectomy
25
8.62
Extra uterine pregnancy
16
5.52
Hysterectomy
14
4.82
Mastectomy
02
0.69
Others
35
12.06
Qualification of surgeon
OBGYN*
188
64.83
GP**
92
31.72
GS***
10
3.45
OBGYN*: obstetrician and gynaecologist; GP**: General practitioner; GS***: General surgeon.
The majority of the staff members were between the ages of 20 and 39 (81.1%), with a smaller proportion aged 40 - 49 (15.7%) and over 50 (2.9%). In terms of work experience, most staff members have 1-5 years of experience (57.1%), followed by 6 - 10 years (15.7%), 11 - 15 years (15.7%), 16 - 20 years (2.9%), and over 20 years (8.6%). Finally, the majority of staff members have received training on Patient Safety (67.1%), while 32.9% have not (see
Table 2
).
3.2. Outcome Results
As shown in
Table 3
below, nearly 38% of study participants reported using SSCL while 62.07% did not. All participants (100%) completed sections 1 and 2 of the SSCL; 60.9% completed section 3, while 39.1% did not.
Figure 2
below summarizes staff members’ perspectives on the barriers to SSCL utilization. Out of 70 staff members interviewed, 56(80%) think that absence of training is a barrier to the use of SSCL; other obstacles mentioned include, in decreasing order inappropriate organization of the hospital (71.4%), insufficient
<xref ref-type="bibr" rid="scirp.144020-"></xref>Table 2. Characteristics of staff members involved in SSCL.
Variables
Frequency (n = 70)
Percentage (%)
Age group
20 - 29
29
41.1
30 - 39
28
40
40 - 49
11
15.7
>50
2
2.9
Work experience
1 - 5
40
57.1
6 - 10
11
15.7
11 - 15
11
15.7
16 - 20
2
2.9
>20
6
8.6
Training on PS
Yes
47
67.1
No
23
32.9
<xref ref-type="bibr" rid="scirp.144020-"></xref>Table 3. SSCL use and completeness.
Variables
Frequency (Percentage %)
SSCL compliance
Yes
110 (37.93%)
NO
180 (62.07%)
Completed
Not completed
Section 1
110 (100%)
00
Section 2
110 (100%)
0.0
Section 3
67 (60.9%)
43 (39.1%)
Figure 2. Staff viewpoints on the barriers to SSCL utilization.
human resources (42.8%), difficulties related to emergency situations 26 cases (40%).
Lack of guidelines on SSCL (Safe Surgery Checklist): 22 cases (33.8%). The Heavy workload was the factor mentioned by the least number of participants 11(15.7%).
This
Table 4
analyzes the association between various factors and the use of a safety checklist. It uses odds ratios (OR) and p-values to assess the significance of these associations. Having established guidelines (p-value < 0.001), Facilities with
<xref ref-type="bibr" rid="scirp.144020-"></xref>Table 4. Factors associated to quality of checklist use.
Variables
Well filled
Poorly filled
OR
P value
Guidelines available
Yes
64
3
284.4
<0.001
No
3
40
Good work organization
Yes
62
5
94.24
<0.001
No
5
38
Teaching hospital
Yes
58
9
24.35
<0.001
No
9
34
Limited staff
Yes
19
24
0.3
0.58
No
48
19
Specialists
Yes
64
4
208
<0.001
No
3
39
good work organization (p-value < 0.001), being a teaching hospital (p-value < 0.001), procedures performed by specialists (p-value < 0.001) appear strongly linked to a higher likelihood of using appropriately a safety checklist. Conversely, limited staff members were associated to poor quality of SSCL but the difference is not statistically significant (p-value = 0.58).
4. Discussion
While prior studies in Cameroon have examined patient safety culture and medical errors
[12]
-
[14]
, our study is among the first to quantitatively assess both compliance (use) and fidelity (completeness) of the Surgical Safety Checklist (SSCL) in obstetric and gynecologic surgeries, specifically in the underserved northern region. The results highlight a low SSCL compliance rate of 38%, underscoring the ongoing challenges in integrating this vital tool into routine surgical practice in semi-urban and resource-limited settings.
Compared to the global average compliance of 75.4%—with rates approaching 100% in high-income countries—the findings in our setting are markedly low and consistent with other LMICs struggling to institutionalize SSCL use
[3]
[15]
-
[18]
. For example, reported compliance rates range from 39.7% to 94% in Ethiopia, 85% in Uganda, and 89.9% in Pakistan
[19]
. Our results align with data from East African referral hospitals, where checklist use has varied widely from 19% to 65%
[19]
.
Encouragingly, the fidelity of checklist use in our study was relatively high when SSCLs were utilized: 100% completion of sections 1 and 2, with 61% overall completion. This mirrors trends observed in LMICs, where adherence to the full SSCL is often suboptimal—particularly the third section, the sign-out phase, which is most frequently neglected
[9]
[20]
. For example, Tadiesse et al. in Ethiopia reported only 35% completion of the sign-out section
[20]
, while implementation improvements in Pakistan raised that figure to 66.7%
[21]
. Our data suggest that when the checklist is started, there is a strong tendency to complete it at least partially, indicating latent awareness of its importance.
4.1. Barriers to SSCL Utilization: A COM-B Analysis
To better understand the underlying reasons for low SSCL uptake, our findings can be interpreted using the COM-B model—a behavioral framework emphasizing Capability, Opportunity, and Motivation as drivers of behavior:
Most staff had not received formal training in patient safety or checklist use. This knowledge gap likely impaired their ability to apply the checklist correctly and consistently. This is consistent with prior studies highlighting that training significantly enhances both compliance and fidelity
[9]
[10]
.
Structural limitations—such as inadequate staffing, overburdened personnel, and inconsistent leadership support—were frequently cited by respondents. Limited time during emergencies and lack of routine monitoring systems further inhibited the integration of the SSCL into daily surgical practice.
Some staff perceived the checklist as optional or bureaucratic, especially during high-pressure situations. Additionally, leadership was not consistently engaged in promoting SSCL compliance, which may signal to staff that it is not a priority. Without reinforcement, the perceived value of the checklist remains low.
Teaching hospitals exhibited higher adherence rates, likely due to increased scrutiny, structured routines, and academic accountability. These institutions may offer a valuable platform for piloting training initiatives and reinforcing safety culture through role modeling and mentorship.
4.2. Implications for Policy and Practice
The findings have several implications. First, merely introducing the SSCL is insufficient—ongoing education, institutional accountability, and systemic reinforcement are essential. Embedding SSCL use into pre-operative workflows, supported by leadership and continuous monitoring, can foster long-term behavior change. Interventions based on the COM-B framework may provide structured pathways to improve uptake—e.g., targeted training (capability), process redesign and staff deployment (opportunity), and leadership engagement and incentive systems (motivation).
Integrating SSCL compliance into hospital quality improvement metrics and national surgical standards could help align behavior with health policy goals, particularly in the context of Cameroon’s commitment following the 2019 Global Ministerial Summit on patient safety
[12]
.
5. Study Limitations
This study was limited to four hospitals in northern Cameroon, which may affect the generalizability of the findings to other regions or hospital types. The sample size was relatively small and no formal power calculation was performed, as this was an exploratory study. Additionally, surgical outcomes were not assessed, limiting our ability to measure the direct impact of SSCL adherence on patient morbidity or mortality. The observational design may also introduce observer bias, despite the efforts made to train and schedule observers systematically.
6. Conclusions
This study revealed a 38% utilization rate of the SSCL in gynecologic and obstetric surgeries in northern Cameroon. While sections 1 and 2 of the checklist were fully completed when used, the sign-out section was often omitted, with 39% of cases lacking proper documentation. These findings highlight a critical gap in surgical safety practices and call for targeted interventions to improve SSCL compliance and fidelity.
Improving patient safety in Cameroon and similar LMICs requires a multifaceted approach: increasing staff training (capability), enhancing resources and workflow organization (opportunity), and fostering a culture that values safety and accountability (motivation). Leveraging models like COM-B may guide the design of effective, context-specific interventions.
What Is Already Known about Surgical Safety Checklist?
What This Study Adds
Authors’ Contributions
TR, NNT, MEI, and IR conceptualized and designed the study. Participants were recruited at the sites by DB and IBE and IR. CN participated in participant recruitment and reviewed the manuscript. In addition, TR, NC, KD wrote the manuscript. NNT revised and scrutinized the study for important intellectual content. All the authors read and approved the final version of the manuscript.
Funding
There was no funding for this research.
Availability of Data
The dataset that was used and analyzed in this study is not publicly available due to ethical considerations. Upon reasonable request, the dataset used is available with the permission of the corresponding author, Dr. Robert Tchounzou.
Ethical Considerations and Consent to Participate
Ethical clearance was obtained from the faculty of Health Sciences of the University of Buea under following reference: Ref. 2023/1930-01/UB/SG/IRB/FHS of 2nd February 2023; administration authorizations were obtained from the directors of different health institutions. For the second part of the study, written consent to participate was sought and obtained from hospital staff.
Consent for Publication
Not applicable.
SupplementData Collection Tool: Modified from WHO Surgical Safety Checklist
Instructions for Use:
Use this data to assess compliance (whether SSCL was used) and fidelity (completeness of each phase)
Item
Description
Response
Section I: Patient and Procedure information
Q1
Hospital Name
[Text]
Q2
Date of Surgery
[DD/MM/YYYY]
Q3
Time of Surgery Start
[HH:MM]
Q4
Type of Procedure
☐ Cesarean Section ☐ Hysterectomy ☐ Myomectomy ☐ EP ☐ Mastectomy ☐ Other
Q5
Surgery Type
☐ Elective ☐ Emergency
Q6
Anesthesia Type
☐ General ☐ Regional ☐ Local
Q7
Surgeon Qualification
☐ Obstetrician-Gynecologist ☐ General Surgeon ☐ General Practitioner
Q8
Was an SSCL form available in patient file or operating room?
☐ Yes ☐ No
Section II: Compliance (Penetration)
Q9
Was the SSCL used during the surgery?
☐ Yes ☐ No
Q10
If “No,” state reason (select all that apply)
☐ Not available ☐ Not aware of SSCL ☐ Emergency case ☐ Lack of time ☐ Individual beliefs ☐ insufficient human resources ☐ work organization ☐ Other___________
Section III: Fidelity (Completeness of Checklist Use)
Checklist Phase
Was the Section Completed?
Who Led the Section?
Q11 Sign-In (Before anesthesia)
☐ Yes ☐ No
☐ Nurse ☐ Anesthetist ☐ Surgeon ☐ Other: ______
Q12 Time-Out (Before incision)
☐ Yes ☐ No
☐ Nurse ☐ Surgeon ☐ Team Leader ☐ Other: ______
Q13 Sign-Out (Before patient leaves OR)
☐ Yes ☐ No
☐ Nurse ☐ Surgeon ☐ Other: ______
Section IV: Barriers to SSCL use (Staff characteristics)
Q14 Age group
Staff’s age in years
☐ 20 - 29 ☐ 30 - 39 ☐ 40 - 49 ☐ >50
Q15 Work experience
Numbers of years of experience
☐ 1 - 5 ☐ 6 - 10 ☐ 11 - 15 ☐ 16 - 20
☐>20
Q16 Ever receive training of Patient Safety
Training in Patient Safety including use of SSCL
☐ Yes ☐ No
Section V: Observed Barriers During Surgery (Tick all that apply (observer’s judgment or staff comments).
Barrier
Observed?
Notes
Q17
Inadequate staffing during operation
☐ Yes ☐ No
Q18
Lack of SSCL-related training
☐ Yes ☐ No
Q19
Team members not engaged in checklist steps
☐ Yes ☐ No
Q20
Checklist steps skipped due to urgency
☐ Yes ☐ No
Q21
Poor intra-team communication
☐ Yes ☐ No
Q22
Language barrier or poor comprehension
☐ Yes ☐ No
Section VI: Observer Details
Q23
Observer Name/Code
[Text]
Q24
Date of Observation
[DD/MM/YYYY]
Q25
Shift Type
☐ Day ☐ Night ☐ Weekend
Q26
Observer Name/Code
[Text]
Q: question.
References
World Health Organization (2008) WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives.
World Health Organization Regional Office for Africa (2008) Patient Safety in African Health Services: Issues and Solutions: Report of the Regional Director. AFR/RC58/8. >https://apps.who.int/iris/handle/10665/19987
NHS England (2019) Decade of Improved Outcomes for Patients Thanks to Surgical Safe-ty Checklist. >https://www.england.nhs.uk/2019/01/surgical-safety-checklist/
Mehta, N., Amaranathan, A., Jayapal, L., Kundra, P. and Nelamangala Ramakrishnaiah, V.P. (2018) Effect of Comprehensive Surgical Safety System on Patients’ Outcome: A Prospective Clinical Study. Cureus, 10, e2601. >https://doi.org/10.7759/cureus.2601
de Vries, E.N., Prins, H.A., Crolla, R.M.P.H., den Outer, A.J., van Andel, G., van Helden, S.H., et al. (2010) Effect of a Comprehensive Surgical Safety System on Patient Outcomes. New England Journal of Medicine, 363, 1928-1937. >https://doi.org/10.1056/nejmsa0911535
Close, K.L., Baxter, L.S., Ravelojaona, V.A., Rakotoarison, H.N., Bruno, E., Herbert, A., et al. (2017) Overcoming Challenges in Implementing the WHO Surgical Safety Checklist: Lessons Learnt from Using a Checklist Training Course to Facilitate Rapid Scale up in Madagascar. BMJ Global Health, 2, e000430. >https://doi.org/10.1136/bmjgh-2017-000430
Golębiowska, M., Golębiowska, B., Chudzik, R., Jarosz-Chudzik, K. and Jasiński, M. (2018) Utilization of Surgical Safety Checklist in Low-and Middle-Income Countries. World Scientific News, 106, 214-225.
Borchard, A., Schwappach, D.L.B., Barbir, A. and Bezzola, P. (2012) A Systematic Review of the Effectiveness, Compliance, and Critical Factors for Implementation of Safety Checklists in Surgery. Annals of Surgery, 256, 925-933. >https://doi.org/10.1097/sla.0b013e3182682f27
Sibhatu, M.K., Taye, D.B., Gebreegziabher, S.B., Mesfin, E., Bashir, H.M. and Varallo, J. (2022) Compliance with the World Health Organization’s Surgical Safety Checklist and Related Postoperative Outcomes: A Nationwide Survey among 172 Health Facilities in Ethiopia. Patient Safety in Surgery, 16, Article No. 20. >https://doi.org/10.1186/s13037-022-00329-6
Gul, F., Nazir, M., Abbas, K., Khan, A.A., Malick, D.S., Khan, H., et al. (2022) Surgical Safety Checklist Compliance: The Clinical Audit. Annals of Medicine&Surgery, 81, Article 104397. >https://doi.org/10.1016/j.amsu.2022.104397
Sotto, K.T., Burian, B.K. and Brindle, M.E. (2021) Impact of the WHO Surgical Safety Checklist Relative to Its Design and Intended Use: A Systematic Review and Meta-meta-Analysis. Journal of the American College of Surgeons, 233, 794-809e8. >https://doi.org/10.1016/j.jamcollsurg.2021.08.692
White, M.C., Daya, L., Karel, F.K.B., White, G., Abid, S., Fitzgerald, A., et al. (2020) Using the Knowledge to Action Framework to Describe a Nationwide Implementation of the WHO Surgical Safety Checklist in Cameroon. Anesthesia&Analgesia, 130, 1425-1434. >https://doi.org/10.1213/ane.0000000000004586
Ding, K., Nguyen, N., Carvalho, M., Dissak Delon, F.N., Mekolo, D., Nkusu, D., et al. (2020) Baseline Patient Safety Culture in Cameroon: Setting a Foundation for Trauma Quality Improvement. Journal of Surgical Research, 255, 311-318. >https://doi.org/10.1016/j.jss.2020.05.068
Shu, D.D. (2019) Patient Safety Awareness and Culture Among Frontline Clinical Workers at Four Clinical Settings in Yaoundé, Cameroon. Manuscript Published Online.
Delisle, M., Pradarelli, J.C., Panda, N., Koritsanszky, L., Sonnay, Y., Lipsitz, S., et al. (2020) Variation in Global Uptake of the Surgical Safety Checklist. British Journal of Surgery, 107, e151-e160. >https://doi.org/10.1002/bjs.11321
Aveling, E., McCulloch, P. and Dixon-Woods, M. (2013) A Qualitative Study Comparing Experiences of the Surgical Safety Checklist in Hospitals in High-Income and Low-Income Countries. BMJ Open, 3, e003039. >https://doi.org/10.1136/bmjopen-2013-003039
White, M.C., Randall, K., Capo-Chichi, N.F.E., Sodogas, F., Quenum, S., Wright, K., et al. (2019) Implementation and Evaluation of Nationwide Scale-up of the Surgical Safety Checklist. British Journal of Surgery, 106, e91-e102. >https://doi.org/10.1002/bjs.11034
Anwer, M., Manzoor, S., Muneer, N. and Qureshi, S. (2016) Compliance and Effectiveness of WHO Surgical Safety Checklist: A JPMC Audit. Pakistan Journal of Medical Sciences, 32, 831-835.
Epiu, I., Tindimwebwa, J.V.B., Mijumbi, C., Ndarugirire, F., Twagirumugabe, T., Lugazia, E.R., et al. (2015) Working Towards Safer Surgery in Africa; A Survey of Utilization of the WHO Safe Surgical Checklist at the Main Referral Hospitals in East Africa. BMC Anesthesiology, 16, Article No. 60. >https://doi.org/10.1186/s12871-016-0228-8
Girma, T., Mude, L.G. and Bekele, A. (2022) Utilization and Completeness of Surgical Safety Checklist with Associated Factors in Surgical Units of Jimma University Medical Center, Ethiopia. International Journal of General Medicine, 15, 7781-7788. >https://doi.org/10.2147/ijgm.s378260
Bashford, T., Reshamwalla, S., McAuley, J., Allen, N.H., McNatt, Z. and Gebremedhen, Y.D. (2014) Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital. Patient Safety in Surgery, 8, Article No. 16. >https://doi.org/10.1186/1754-9493-8-16