Taking into account recent cases of surgical mishaps in the state, the Kerala government has issued an order introducing a modified surgical protocol list.

The new surgical protocol, submitted by the Directorate of Medical Education under the direction of the Health Department, has been established based on the WHO surgical safety checklist. It comes at a time when several allegations of medical negligence have been reported in the state.

The directions issued through the order outline structured interventions across three stages — preoperative actions, use of the WHO surgical safety checklist in the operating room, and additional measures in the surgical process.

Prior to the operation, the informed consent form must be signed and proper patient briefing and counselling must be undertaken. Additionally, appropriate colour-coded wristbands for emergency and elective procedures must be applied, which include all relevant patient details.

The nurse in charge and the ward doctor of the corresponding unit must fill in and sign the preoperative checklist. This will be verified upon entry into the operating room by the nursing officer in charge of the preoperative area and the preoperative anaesthesia personnel in charge of the table. The checklist must then be signed before the patient enters the theatre.

In the operating room, the implementation of the WHO checklist must be ensured in all cases under general, regional and local anaesthesia by responsible members of the surgical team.

During the sign-out stage, which occurs after the procedure is complete but before the patient leaves the operating room, the scrub nurse must ensure that only radio-opaque objects are placed on the operating trolley, and a circulating nurse must supervise the movement of any additional instruments or disposables. The instrument and mop counts must be mandatorily written on a whiteboard inside the operating room and cross-checked by the scrub nurse at the end of the case.

However, the order permits the modification of various checklists based on the concerned specialties in accordance with their departmental protocols. These must be submitted to the administration in both print and digital formats for incorporation into institutional protocols.

The order also directs the implementation of safety checklists in minor procedures performed under local anaesthesia, where nursing staff is often not available to assist or document the procedure.

“Since all checklists necessitate a two-point verification — one by the nurse and another by the doctor — it is crucial to ensure the availability of a nurse and nursing assistant in all procedure rooms where invasive procedures are performed,” the order says.

The move comes at a time when reports of medical negligence have surfaced across the state. In February, a surgical forcep was found inside the abdomen of Usha Joseph, an Alappuzha native who had undergone surgery at the Government Medical College Hospital in Vandanam five years ago.

In 2025, two other cases of alleged medical negligence also raised controversies over surgical safety in the state’s hospitals.

Vinodhini, a resident of Palakkad, had her arm amputated following a botched procedure for fracture management at the Palakkad District Hospital in September 2025. The case of alleged medical negligence escalated into a major row, forcing the government to take punitive action against the doctors responsible.

In a similar case, Sumayya, who had undergone thyroid surgery at the Thiruvananthapuram General Hospital on March 20, 2023, later developed breathing difficulties and swelling. In March 2025, an X-ray examination conducted at the Regional Cancer Centre revealed that a guide wire — part of a central line used to administer medicines through blood vessels — had been left inside her body after the surgery.