The use of checklists in surgery is a best practice.1 There is a plethora of evidence that suggests using the WHO Surgical Safety Checklist (SSC) reduces complications such as pneumonia,2 intraoperative blood loss,2 3 sepsis,2 unplanned intubation,2 urinary tract infections,2 wound infections,2–4 30-day readmissions and 30-day mortality.2–4 The SSC has three components, which need to be carried out for each phase of a surgical procedure, including sign-in, timeout and sign-out.5 The SSC serves as an aide memoir that includes vital information to prompt team discussions and actions that may otherwise be overlooked or forgotten, thereby promoting clear, consistent and timely communications among team members that prevents errors and enhances patient safety.6 Importantly, the SSC is more than merely a routine activity. When used as intended, it can promote effective teamwork and communication and enable surgical team members to voice their concerns regardless of their professional role.7

The challenges in SSC implementation are well documented4 8 9 and attributed to a myriad of factors that involve every level of the healthcare organisation. Contextual challenges that impact checklist adoption include the level of physician involvement,4 8 workflow patterns,3 10 a lack of organisational support8 and a lack of customisation.8 Therefore, it is no surprise that previous research has demonstrated inconsistent results concerning SSC compliance, particularly for frequency and completeness of usage.3 4 In the context of planned surgeries, a systematic review and meta-analysis of 10 studies found that observed checklist compliance varied, with rates ranging from 12% to 100%.5 Although checklist compliance is increasingly being monitored in healthcare settings, it is not enough to simply know if the ‘checks’ are performed in practice.5 Measuring intervention fidelity is necessary as it is an important component of the implementation of any quality improvement (QI) intervention, adding further evidence about the causal relationship between the intervention and outcome.