Auditor Name



What Specialty is it?

If other what is it?

What is the name of the Consultant on the list?

Select date


Select date
Where was the briefing conducted? ie. Anesthetic Room, Corridor etc.

What personnel are present?

Consultant Surgeon

Surgical Registrar

Consultant Anaesthetist

Anaesthetic Registrar

Anaesthetic Practitioner (ODP/Nurse)

Theatre Scrub Lead 1

Scrub/Circulating Staff 2

Scrub/Circulating Staff 3





Add photo of team & location


Planned Surgical Procedure for all patients discussed?

Order of the List Confirmed

What is the reason? ie. only 1 patient

Has the Patient's been reviewed by the anaesthetist?

If no or n/a, why? ie. Patients not here or Local Anaesthetic only

Has equipment been discussed?

Have any equipment issues been identified?

The team need to have agreed how and who to escalate this to by an identified team member.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.