SURGICAL 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]