World Health Organization Surgical Safety Checklist

• Medical Record Number:

• Patient Name:

• Type of Surgery:

• Date/Time of Surgery:

  Date

• Surgeon:

• Location:
  Address

• Assisting Personnel:

SIGN IN

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

  Yes

  No

• Is the site marked?

  Yes

  No

  NA

• Is the anaesthesia machine and medication check complete?

  Yes

  No

  NA

• Does the patient have a:

• Known allergy?

  Yes

  No

• Difficult airway or aspiration risk?

  Yes

  No

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

  Yes

  No

TIME OUT

• Confirm all team members have introduced themselves by name and role

  Yes

  No

  NA

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

  Yes

  No

  NA

• Has antibiotic prophylaxis been given within the last 60 minutes?

  Yes

  No

  N/A

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?

  Yes

  No

• To Nursing Team:

• Has sterility (including indicator results) been confirmed?

  Yes

  No

  NA

• Are there equipment issues or any concerns?

  Yes

  No

  NA

• List concerns

• Is essential imaging displayed?

  Yes

  No

  NA

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?)

  Yes

  No

  NA

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

  Yes

  No

  NA

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

  Yes

  No

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

  Yes

  No

Sign Out

• Nurse Verbally Confirms:

• The name of the procedure?

  Yes

  No

• Completion of instrument, sponge and needle counts

  Yes

  No

  NA

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

  Yes

  No

  NA

• Whether there are any equipment problems to be addressed

  Yes

  No

• To Surgeon, Anaesthetist and Nurse:

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

  Yes

  No

• Surgeons name and signature

  Sign