In this review, it is seen that, based on articles published in 2024–2025, surgical safety has been examined in eight main ways within the context of patient safety. Although these themes overlap with each other, they make it possible to distinguish the core analytical levels on which the articles focus.
The first theme is the relationship between the implementation of the WHO Surgical Safety Checklist (SSC), the level of adherence, and patient outcomes. Studies conducted in Somalia, Vietnam, India, Ethiopia, Croatia, and other low- and middle-income countries report that after education and audit-feedback interventions, complete implementation rates of the checklist increased from around 37% to as high as 98%, with parallel reductions in complications and errors (Dirie et al., 2024; Badasa et al., 2025; Kausar et al., 2025; Thanh et al., 2025; Krstulovic et al., 2025). Observational studies from Sudan and India indicate that critical steps such as patient identification, equipment checks, and the availability of imaging are almost always completed, whereas deficiencies persist particularly in the “sign-out” section before discharge from the operating room (Gasoma & Marouf, 2024; Ohagwu et al., 2025). In gynecology-obstetrics and cleft lip/palate surgery, SSC-based programs have achieved relative reductions of up to 40–60% in indicators such as infection, fistula, dehiscence, and other morbidities, while the effect on mortality has been more limited (Alamnie et al., 2024; Amrita et al., 2024; Patel et al., 2024). In a large retrospective analysis from Italy, checklists that were incomplete or contained non-conformities were associated with approximately a two-fold increase in complication risk, demonstrating that the gap between “on-paper” completion and genuine clinical implementation translates directly into patient safety outcomes (Rossi et al., 2025). Two major studies using OR Black Box data showed that in operations where the checklist was conducted more thoroughly and with greater team participation, mortality, ICU admission, and length of stay were significantly reduced, whereas these gains disappeared in cases where no debrief was performed (Al Abbas et al., 2024; Riley et al., 2024). The key conclusion of this theme is that not merely the existence of the checklist, but its complete and meaningful implementation, is decisive for patient safety.
The second theme concerns how surgical teams’ knowledge, attitudes, perceptions, and psychological safety shape surgical safety. Multicenter studies covering India, Somalia, Peru, and Jordan show that although most healthcare workers have a positive attitude toward the checklist, knowledge gaps, time pressure, and lack of training lead to steps being omitted (Srivastava et al., 2025; Dirie et al., 2025; Sapaico et al., 2025; Yaseen et al., 2025). Qualitative studies from South Africa, Indonesia, and Canada emphasize that hierarchical power struggles, a culture of silence, and siloed training programs transform the checklist from an effective safety tool into a mechanical ritual (Sima et al., 2024; Dhamanti et al., 2025; Lim et al., 2024). Two ethnographic studies from Canada reveal that workarounds such as “pre-filling” the checklist not only create ethical dilemmas but also reduce the checklist to a mere formality that satisfies internal legal reporting requirements rather than patient safety goals (Facey et al., 2024). A cross-sectional study from Denmark demonstrates that in environments where team members feel listened to and perceive that the checklist improves teamwork, psychological safety scores are significantly higher, whereas they are markedly lower among staff who regard the checklist as a “waste of time” (Moller et al., 2024). These findings indicate that the cognitive and emotional framing of the checklist is as important as technical protocols for real adherence and patient safety outcomes.
The third theme is organizational readiness, management processes, and system-level quality improvement initiatives. Using data from seven different safety projects, the Safe Surgery Organizational Readiness Tool shows that a readiness profile composed of nine factors, including change preparedness, a learning-oriented team structure, communication, and institutional capacity, predicts the likelihood of success of safety initiatives (Hayirli et al., 2024). At Wollega University Hospital in Ethiopia, a multidimensional quality improvement project increased SSC use from 56% to 100% within one year through six change ideas such as leadership support, training, feedback, and supervision (Badasa et al., 2025). In Croatia, after three successive interventions (an official letter signed by the chief executive, department-level meetings, and quality audits), checklist completion rates increased significantly and sustainably in all departments, with near-complete adherence particularly for “sign-out” and staff information (Krstulovic et al., 2025). Initiatives such as the MOMENTUM Safe Surgery project and the SIRT program in Nigeria demonstrate that strategies that bring together national-level stakeholders, integrate safety into budgeting processes, and focus on equipment maintenance strengthen the overall safety of the surgical ecosystem (Atta et al., 2024; Udeigwe-Okeke et al., 2025). This theme shows that patient safety must be addressed not only through behaviors in the operating room but also in conjunction with organizational capacity, leadership, and financial sustainability.
The fourth theme is the enhancement of surgical safety through education, mentorship, gamification, and supervised specialist training. The Lifebox McCaskey Fellowship program in Ethiopia, through interdisciplinary team training and local mentorship, strengthened participants’ teamwork, leadership, and research skills and led to the initiation of local quality improvement projects (Negash et al., 2024). In Nigeria, the Clean Cleft program in cleft surgery used process-based training and supervised practice grounded in the SSC to significantly reduce infection, fistula, and dehiscence rates (Alamnie et al., 2024). The RAS Olympics study with robotic surgery teams in the United States showed that gamified team training particularly reduced major flow disruptions during the console phase and thus shifted team performance in favor of safety (Cohen et al., 2024). In studies on thoracoscopic resection and pediatric appendectomy, strategies such as innovative patient positioning and assigning high-risk cases to experienced surgeons reduced complication rates and operative time while maintaining training opportunities for residents (Tsukamoto et al., 2025; Pandey et al., 2025). In cervical disc surgery, surgeons without certification achieved complication rates and patient-reported outcomes similar to experts when operating under direct supervision, indicating that structured supervision can foster competence while preserving surgical safety (Okubo et al., 2025). Overall, this body of evidence shows that educational design can be strategically structured to optimize both learning outcomes and concurrent patient safety.
The fifth theme is the use of digital, robotic, and artificial intelligence–based technologies in surgical safety. In China, an AI-assisted perioperative verification system significantly increased the execution and standardization rates of safety verification procedures in urologic and general surgery cases and simultaneously improved surgeon and nurse satisfaction (Yu et al., 2024). A deep learning–based navigation system developed to prevent pancreatic fistula in laparoscopic gastrectomy provided real-time visualization of anatomical “dimpling line” structures and was judged by expert surgeons to be a clinically meaningful and safety-enhancing tool (Aoyama et al., 2024). In endoscopic pituitary surgery, a telestration system that allows mentors to draw directly onto the surgical field improved the concordance between the planned and actual bone window and shortened training time (Tanaka et al., 2024). Large series of robot- and image-guided pedicle screw placement and iMRI-assisted brain tumor surgery showed that among thousands of screws and more than two thousand cases, mortality rates were below 0.1% and serious neurological complications were negligible, demonstrating that technology can create a safety buffer in high-volume centers (Widmann et al., 2024; Suzuki et al., 2024). Comparisons of wide-angle BirdView camera systems and robotic rectal surgery suggest a potential not only to shorten operative time but also to reduce the risk of organ injury due to blind spots (Ogi et al., 2025; Li et al., 2025). These studies show that technology is not a stand-alone solution, but when integrated with appropriate training and process design, it can shift intraoperative errors, operative time, and learning curves in favor of patient safety.
The sixth theme is the enhancement of safety through optimization of surgical technique, patient selection, and risk stratification. Studies in otorhinolaryngology, adenoidectomy, gynecologic hysteroscopy, and gastric cancer surgery show that strict adherence to protocols and appropriate technique selection can halve intraoperative complications and shorten recovery times (Kumar et al., 2024; Losgar et al., 2025; Ferla et al., 2025; Li et al., 2024). In cardiovascular and orthopedic surgery, novel technical approaches—for example, the open left diaphragm method, laparoscopic appendectomy in the lateral decubitus position, or identifying high-risk screw trajectories in calcaneal plating—have significantly reduced specific complications such as respiratory events, neurovascular injury, and serosal tears (Kanaji et al., 2024; Pandey et al., 2025; Kalem et al., 2025). A new ultrasound method for preoperative prediction of abdominal wall–bowel adhesions can detect moderate-to-severe adhesions with high sensitivity, offering the potential to modify the surgical plan and prevent organ injuries (Nishino et al., 2024). From the patient safety perspective, all these technique- and risk classification–oriented studies indicate that complications are closely linked not only to the checklist but also to the micro-technical details of surgery and patient selection.
The seventh theme is infection control and environmental/instrument-based safety. A study of bacterial air quality in operating rooms in Slovenia showed that both in quiet and active periods, all rooms remained below the 10 CFU/m³ threshold and no pathogenic bacteria or molds were detected, although staphylococcal species originating from skin flora were predominant (Gradisnik et al., 2024). The SIRT program in Nigeria, which builds capacity for surgical instrument maintenance and repair, reported that 99.6% of 1,623 instruments were successfully repaired and that in half of the participating hospitals an internal repair workshop was established (Udeigwe-Okeke et al., 2025). In the Clean Cleft and other SSC-based programs, improvements in process indicators such as hand and field antisepsis, integrity of sterile draping, and timing of antibiotics were associated with marked reductions in surgical site infections (Alamnie et al., 2024; Gasoma & Marouf, 2024). This theme underscores that classical “asepsis–antisepsis” principles remain the cornerstone of surgical safety, but that sustainability requires addressing infrastructure, training, and organizational support jointly.
The eighth theme is patient-centered dimensions, including health literacy, patient perceptions, quality of life, and the safety of specific population groups. A study among safety-net patients in the United States showed that different health literacy assessment tools yield divergent results and that these differences may be critical for the comprehension of surgical instructions (Fajemisin et al., 2025). The Patient Perspective on Surgical Safety Scale developed in Greece had internal consistency coefficients between 0.79 and 0.85, indicating that patients can distinguish and evaluate dimensions such as safety, communication, and emotional reassurance during the surgical process (Toska et al., 2024). A multi-method study in New Zealand’s cardiac surgery and catheterization laboratories found that the checklist strengthened patients’ perceptions of “being cared for” and being treated with cultural respect, yet teams expressed reservations about actively involving patients in the checklist process (Jowsey et al., 2025). Interventions such as auditory implant conversion surgery, dermatologic surgery in older patients with keratinocyte carcinoma, and breast-sharing reconstruction approaches have maintained low complication rates while providing significant improvements in quality of life and aesthetic outcomes, expanding the notion of “safe and effective surgery” to encompass both the absence of complications and patient satisfaction (Ordonez et al., 2025; Fontana et al., 2025; Szychta, 2025). These studies emphasize that patient safety should not be limited to reducing mortality and morbidity but must also include patient experience, perception, and long-term quality of life.
Overall, the 2024–2025 literature examines surgical safety on the axis of patient safety at eight main levels: checklist implementation, cultural–organizational context, education and mentorship, digital–robotic technologies, technical and risk management, infection and environmental control, and patient-centered outcomes. This multilayered approach clearly shows that surgical safety strategies must be based not on a single intervention, but on mutually reinforcing systemic components.
References:
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Yu, X., Wang, Z., Wu, J., & Weng, D. (2024). Artificial intelligence-based perioperative safety verification system improved the performance of surgical safety verification execution. American Journal of Translational Research, 16(4), 1295–1305.