Before induction of anaesthesia

SIGN IN

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

Is the site marked?

Is the anaesthesia machine and medication check complete?

Does the patient have a:

Known allergy?

Difficult airway or aspiration risk?

Risk of >500ml blood loss (7ml/kg in children)?

Before skin incision

TIME OUT

Confirm all team members have introduced themselves by name and role

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

Has antibiotic prophylaxis 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?

Human Factors & Teamwork

Does the surgeon or anaesthetist ask a "What if..' question to prime a team emergency response (e.g. What will we need if we have a major haemorrhage? who will get what, and where?)

Does the surgeon remind team that he/she expects them to speak up and look for red flags?

Is the team given an emergency call out word - e.g. 'DELTA!' - that when used by a team member will halt all activity?

Have all team members been present in the huddle and actively listening during Time out?

Before patient leaves operating room

Sign Out

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?

Surgeons name and signature
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.