Improving Surgical Safety in Somalia a Closed-Loop Audit Study of WHO Surgical Safety Checklist Adherence

Background: Surgical safety is a global health priority, yet its consistent application in low- and middle-income countries remains a challenge due to systemic, cultural, and resource-related barriers. The World Health Organization's Surgical Safety Checklist (SSC) has been shown to reduce perioperative complications, but evidence from fragile health systems such as Somalia remains scarce. Methods: This prospective closed-loop clinical audit was conducted at Dr. Sumait Hospital, a tertiary referral and teaching facility in Mogadishu, Somalia. A total of 160 surgical procedures were observed across two audit cycles. The first cycle established baseline compliance, while the second followed a structured intervention comprising targeted staff education sessions, strengthened leadership involvement, and placement of visual reminders and wall posters in operating theatres. Checklist adherence was assessed across the sign in, time out, and sign out phases using a standardized 25-item observation tool. Data were analyzed using the Wilcoxon signed-rank test, with significance set at p < 0.05. Results: Overall checklist compliance increased significantly from 51.38% in the first cycle to 93.01% in the second (p < 0.001). Improvements were observed across all three SSC phases: sign in compliance rose from 54.62% to 88.19%, time out compliance from 50.60% to 96.94%, and sign out compliance from 47.29% to 95.01%. The most substantial gains were linked to improved team communication during the time out phase. However, checklist items requiring anticipatory planning, such as risk assessment for major blood loss, showed relatively lower improvements. Conclusion: Context-sensitive, low-cost interventions-including focused education, leadership reinforcement, and visual prompts-can markedly improve adherence to the WHO Surgical Safety Checklist in resource-limited settings. These findings underscore the SSC's potential to strengthen surgical safety culture in Somalia and offer a practical model for similar fragile health systems aiming to reduce preventable perioperative harm.