Before induction of anaesthesia

(with at least nurse and anaesthetist)

Has the patient confirmed his/her identity, site, procedure, and consent?

Is the site marked?

Is the anaesthesia machine and medication check complete?

Is the pulse oximeter on the patient and functioning?

Does the patient have a:

Known allergy?

Difficult airway or aspiration risk?
Risk of >500ml blood loss (7ml/kg in children)?

Before skin incision

(with nurse, anaesthetist and surgeon)

Confirm all team members have introduced themselves by name and role

Confirm the patient's name, procedure, and where the incision will be made

Had antibiotic prophylaxis have been given within the last 60 minutes?

Anticipated Critical Events

To Surgeon:

What are the critical or non-routine steps?

List critical or non-routine steps

How long will the case take?

Include estimated time

What is the anticipated blood loss?

Include blood loss estimate

To Anaesthetist:

Are there any patient specific concerns?

To Nursing Team:

Has sterility (including indicator results) been confirmed?

Are there equipment issues or any concerns?

List concerns

Is essential imaging displayed?

Before patient leaves operating room

(with nurse, anaesthetist, and surgeon)

Nurse Verbally Confirms:

The name of the procedure

Completion of instrument, sponge, and needle counts

Specimen labelling (read specimen labels aloud, including patient name)

Whether there are any equipment problems to be addressed

To Surgeon, Anaesthetist, and Nurse:

Are there any key concerns for recovery and management of this patient?

List concerns

Surgeon name and signature