A surgical safety checklist is a short set of checks the operating team says aloud at three pauses: before anesthesia, before the incision, and before the patient leaves the room. Copy a free template built on the WHO model with room for your local items, see a completed appendectomy checklist and a time out that stopped a knee replacement, and check what goes in each pause.
Blank surgical safety checklist template
FreeSURGICAL SAFETY CHECKLIST Patient: [Name, date of birth, record number] Date: [Date] Room: [Operating room] Procedure booked: [Procedure, side, and level, as on the operating list] Surgeon: [Name] Anesthesia professional: [Name and role] Circulating nurse: [Name] Scrub: [Name] Checklist version: [Your organization's checklist and version, based on the WHO Surgical Safety Checklist] SIGN IN: BEFORE ANESTHESIA Led by: [Name and role, often the anesthesia professional or circulating nurse] Time: [Time] Patient taking part: [Awake and answering, or who answered instead, such as a parent, guardian, or the person who consented] Identity: [Name and date of birth said by the patient, matched to wristband and record] Procedure and side: [In the patient's own words, matched to the consent and the operating list] Consent: [Signed consent present; procedure, side, and level match] Site mark: [Mark seen, same side and level as the consent, or not applicable and why] Anesthesia safety check: [Machine, drugs, and suction checked, and by whom] Pulse oximeter: [On the patient and reading] Allergies: [Drug, latex, and other allergies with reactions, or none known] Airway and aspiration risk: [Concerns, and the plan and equipment ready] Expected blood loss: [Estimate; over 500 mL in an adult, or 7 mL per kg in a child, means access and blood ready] Local items: [Such as pregnancy test, glucose, anticoagulant held, hearing aids, or interpreter] TIME OUT: BEFORE THE INCISION Led by: [Name and role] Time: [Time] Everyone stopped: [All work paused, music down, attention on the person leading] Introductions: [Each person in the room by name and role, including anyone new since sign in] Confirmed aloud: [Patient, procedure, side, and site, matched to the consent, the mark, and the images] Surgeon: [Critical or unexpected steps, expected length, expected blood loss] Anesthesia: [Concerns for this patient, airway, fluids, and blood] Nursing: [Sterility indicators confirmed; equipment problems or concerns] Antibiotic prophylaxis: [Drug, dose, and time started; within 60 minutes before incision, or 120 for vancomycin or a fluoroquinolone; or not indicated and why] Imaging displayed: [Which images, labelled with name and side, or not needed] Implants and special equipment: [Implant, side, and size range in the room; equipment checked] VTE prophylaxis: [Mechanical device on and working; drug plan] Local items: [Such as warming, positioning, tourniquet, or glucose] Decision: [Proceed, or stop: what didn't match and what the team did] SIGN OUT: BEFORE THE PATIENT LEAVES THE ROOM Led by: [Name and role, usually the circulating nurse] Time: [Time] Procedure recorded: [The procedure as done, and any change from the booking] Counts: [Instruments, sponges, and needles correct, or what was missing and the action taken] Specimens: [Each specimen and its label, read aloud with the patient's name, or none] Equipment problems: [What failed, and how it was reported] Handover for recovery: [Surgeon, anesthesia, and nursing concerns: pain, nausea, drains, monitoring, blood thinners, antibiotics] CONFIRMED BY Sign in: [Names and roles, time] Time out: [Names and roles, time] Sign out: [Names and roles, time] Variances: [Anything that stopped or changed the case, and the safety report number]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Emergency operating list, evening, general anesthesia
30-year-old woman, 64 kg, with 18 hours of right lower abdominal pain. CT at 17:40 showed acute appendicitis without perforation. Booked for laparoscopic appendectomy. Surgeon Dr. Okafor, anesthesiologist Dr. Lindqvist, circulating nurse Sam Reyes, scrub nurse Mei Tanaka.
Led by Dr. Lindqvist at 21:12, patient awake on the table. She gave her name and date of birth, matching her wristband and chart. In her words: “keyhole surgery to take out my appendix.” Consent signed at 19:05 for laparoscopic appendectomy, possible open; matches the list. Site mark: not applicable, a single organ with no side, per local policy. Anesthesia check done at 20:50. Pulse oximeter on, reading 99%. Allergy: amoxicillin, a rash at age 8, no hives, swelling, or breathing trouble; cefazolin suitable. Airway: Mallampati 1, normal neck movement. Aspiration risk: acute abdomen, vomited at 16:00, so rapid sequence induction with suction ready. Blood loss over 500 mL: not expected; 18-gauge IV in place. Local items: urine pregnancy test negative at 18:30; last meal at 13:00.
Led by Dr. Okafor at 21:34; everyone stopped. Five people introduced by name and role, including surgical resident Dr. Haddad, who arrived after sign in. Patient, procedure, and approach confirmed aloud against the consent. Surgeon: three ports, about 45 minutes, conversion to open if the view is poor, blood loss under 50 mL. Anesthesia: smooth rapid sequence induction; Apfel score 3, so two antiemetics planned. Nursing: sterility indicators checked; camera, insufflator, and stapler tested. Antibiotic: cefazolin 2 g and metronidazole 500 mg IV, started at 21:20. Imaging: CT on screen, labelled with her name. Implants: none. VTE prophylaxis: calf compression on both legs, working. Decision: proceed. Incision at 21:38.
Led by Sam Reyes at 22:16, during skin closure. Procedure recorded: laparoscopic appendectomy, no conversion. Counts: instruments, 10 sponges, and 3 needles correct, called by both nurses together. Specimen: appendix, label read aloud with her name, date of birth, and record number. Equipment: the camera image dropped out twice; scope tagged and reported to biomedical engineering. For recovery: inflamed but not perforated, so no antibiotics after surgery; acetaminophen and ketorolac on schedule, oxycodone if needed; home tomorrow if she’s eating and walking.
Sign in, 21:12: Dr. Lindqvist, anesthesiology; Dr. Okafor, surgery; Sam Reyes, circulating nurse. Time out, 21:34: Dr. Okafor; Dr. Lindqvist; Sam Reyes; Mei Tanaka, scrub nurse; Dr. Haddad, surgical resident. Sign out, 22:16: Sam Reyes; Mei Tanaka; Dr. Okafor; Dr. Lindqvist. Variances: none. Left the room at 22:27.
Elective joint replacement list, morning, spinal anesthesia with light sedation
71-year-old man with severe right knee osteoarthritis, booked for a right total knee replacement. Surgeon Dr. Brennan, anesthesiologist Dr. Achebe, circulating nurse Joanne Pike, scrub nurse Tom Varga.
Led by Joanne Pike at 07:42. He gave his name and date of birth, matching his wristband. In his words: “a new right knee.” Consent signed in clinic on October 12 for a right total knee replacement; the list says right. Site mark: recorded as present. No one compared its side with the consent. Anesthesia check done. Pulse oximeter on, reading 96%. Allergies: none known. Airway: no concerns; nothing to eat since midnight, clear fluids until 05:30. Blood loss over 500 mL: not expected with tranexamic acid; group and screen valid. Local items: hearing aids in so he could take part; metformin held this morning.
Spinal at 07:50, cefazolin 2 g IV at 08:02. The leg with the mark was positioned, prepped, and draped. Time out led by Dr. Brennan at 08:21; everyone stopped and was introduced. Joanne read the consent aloud: right total knee replacement. The mark in the sterile field was on the left knee, and the X-ray on screen was labelled right. Dr. Brennan called a stop at 08:22. No incision. Instruments covered.
Checked every source: signed consent, right; clinic letter of October 12, right; X-rays, severe right medial joint space loss; operating list, right; his own words at sign in, right. Only the mark was different. He was lightly sedated, so the team relied on the documents and his answer at sign in. At 08:30, Dr. Brennan, Dr. Achebe, and Joanne agreed to proceed on the right. Left drapes removed; skin intact, not cut. Tourniquet moved to the right thigh. Dr. Brennan marked the right knee at 08:34 with the consent in hand, and the right leg was prepped and draped. Implants rechecked after the side change: right femoral components, sizes 4 to 6, in the room.
Full time out again at 08:49, led by Dr. Brennan, every item said aloud. Consent, mark, X-ray, and implant side all right. Antibiotic: cefazolin at 08:02, still inside 60 minutes of the planned incision. Tranexamic acid 1 g IV at 08:45. VTE prophylaxis: foot pump on the left leg; apixaban 12 to 24 hours after surgery, per the joint replacement protocol. Decision: proceed. Incision at 08:51.
Led by Joanne Pike at 10:18. Procedure recorded: right total knee replacement, cemented. Counts correct. Specimens: none; bone cuts discarded per local policy. Implant stickers in the record. Equipment: no problems. For recovery: the side change and the report; check the spinal has worn off before he stands; first walk with physical therapy this afternoon.
Sign in, 07:42: Joanne Pike; Dr. Achebe; Dr. Brennan. Time out, 08:21, stopped by Dr. Brennan; repeat at 08:49; sign out, 10:18: Dr. Brennan, Dr. Achebe, Joanne Pike, and Tom Varga each time. Variance: site mark on the wrong knee, caught at the time out, no incision. Safety report 26-1184 filed at 10:40 by Joanne Pike. At 14:30 Dr. Brennan told him and his daughter what happened, and that the left knee was cleaned and draped but not cut. The review found the mark was made in the holding area without the consent in hand, and he wasn’t asked to point to his knee. Sign in now means looking at the mark beside the consent.
The checks done before induction or the block, with the patient awake, so they can say who they are and what they’re having done.
Avoid: Asking “You’re having your left knee done, right?” A nervous patient will say yes. Ask an open question, and let them tell you.
The last check before the skin is cut. Everyone stops, each person is named, and the surgeon, anesthesia professional, and nurse each say what the others need to know.
Avoid: A time out read over the noise of setup. If anyone is still working, it isn’t a pause. Wait until the room is quiet.
Closes the case: what was done, that nothing was left behind, that specimens are labelled, and what recovery needs to know.
Avoid: Leaving it until the bed is moving. Many teams do it during skin closure, while the surgeon is still at the table.
WHO built its checklist to be adapted. Add the checks your rooms need, and keep it short enough that people say every line.
Avoid: Adding items until the list takes several minutes. Test each change in a few rooms first, and take out what no one uses.
Who led each pause, who answered, and when. If the case stopped or changed, say what happened and what was reported.
Avoid: A row of ticks with no names. When something goes wrong, the team needs to know who said what, and when.
A time out over the noise of setup is a list, not a pause. Everyone stops, turns to the person leading, and answers aloud.
A mark on the wrong side passes this check unless someone compares it with the consent. Look at the mark, and say the side aloud.
The checklist works because the surgeon, anesthesia professional, and nurse each speak. A nurse reading every role alone loses the cross-check.
If the incision slips, check the dose is still inside your protocol’s window. In long cases, give cefazolin again at 4 hours, and after blood loss over 1,500 mL.
If a count doesn’t match, search the field and the room, and get an X-ray if your policy says so. Write what was done before the patient leaves.
The concerns for recovery are what the next team needs most. Say them while the surgeon and anesthesia professional are both still in the room.
Vero Scribe drafts the checklist record in your template from the team’s spoken checks, with the patient’s consent and where your organization allows it, or from your dictation after the case. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
A one-page checklist published by the World Health Organization in 2008 and revised in 2009, as part of its Safe Surgery Saves Lives program. It has 19 items in three pauses: before anesthesia, before the incision, and before the patient leaves the operating room. WHO encourages teams to add and change items to fit local practice, and most hospitals use their own version built on it.
Sign in, before anesthesia: identity, procedure, site, consent, the anesthesia check, allergies, airway, and blood loss risk. Time out, before the incision: introductions, a final check of patient, site, and procedure, each role’s concerns, the antibiotic, and imaging. Sign out, before the patient leaves the room: the procedure done, counts, specimens, equipment problems, and concerns for recovery.
One person runs it, often the circulating nurse, sometimes the surgeon. What matters more is that the whole team stops, and the surgeon, anesthesia professional, and nurse each confirm their own items aloud. Anyone in the room can stop the case if something doesn’t match, and the record names who led and who confirmed.
In WHO’s study of 8 hospitals in 8 cities, published in 2009, deaths fell from 1.5% to 0.8% and inpatient complications from 11.0% to 7.0% after teams started using it. Later studies of hospitals required to adopt it found smaller or no changes. The benefit comes from teams that stop, talk, and act on what they hear, not from the form.
Yes. WHO designed it to be adapted: add the checks your rooms need, such as a pregnancy test, implant side, or glucose, and word items the way your teams speak. Keep the core checks, test changes in a few rooms first, and keep it short enough that every line gets said.
Start it within 60 minutes before the incision, or within 120 minutes for vancomycin and fluoroquinolones, which take longer to infuse. Give it again in long cases, at 4 hours for cefazolin, and after blood loss over 1,500 mL. The time out is the last chance to check it was given.
The surgeon doing the procedure, or a delegate who will be there for it, with the patient awake and taking part, and the consent in hand. The mark should still be visible after draping. Procedures on a single organ or with no side may not need one; follow your organization’s policy.
No. The time out is the second of the three pauses, just before the incision. The checklist also covers the checks before anesthesia, with the patient awake, and the checks before the patient leaves the room.
Yes. Copy it, or download it as a Word or text file. No account needed.
A patient leaving or refusing care: the recommendation, capacity, risks in plain words, alternatives, signature or refusal to sign, and the care still given.
A patient’s authorization to release health information: who sends and receives it, what goes, sensitive records, purpose, end date, rights, and the release log.
Consent to a procedure or treatment: benefits, risks, alternatives, capacity, signatures, and the discussion note.
A parent names another adult to consent to their child’s care: dates, what it covers, health details, and signatures.
Screening questions, consent or declination, and a record of each dose: lot, expiry, site, observation, and the next dose due.
Consult notes, perioperative context, and follow-up, drafted for your review.
Pre-anesthesia assessments and patient instructions, drafted from the visit.
Patient-specific consent forms built from your clinic’s templates.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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