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WHO Surgical Safety Checklist Template

A surgical safety checklist should be used before the administration of anesthesia, making a skin incision, and prior to a patient's departure from the operating room. The World Health Administration (WHO) provides a list of surgical checkpoints to complete throughout the course of a patient's operation to protect them from human error and the risk of developing a post-op infection. Check the following before beginning the procedure:

  • •Paiteint Idenity
  • •Site
  • •Procedure
  • •Consent
  • •Site Marked
  • •Anesthesia Safety Check
  • •Pulse Oximeter

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WHO Surgical Safety Checklist Template

Before induction of anaesthesia

Sign In

Patient has confirmed:
Site marked
Anesthesia safety check completed
Pulse oximeter on patient and functioning
Does Patient have a:
Known allergy?
Difficult airway/aspiration risk?
Risk of >500 ml blood loss (7ml/kg in children)

Before skin incision

Time out

Confirm all team members have introduced themselves by name and role
Surgeon, anesthesia professional and nurse verbally confirm Patient Site Procedure


SURGEON REVIEWS: What are the critical or unexpected steps, operative duration, anticipated blood loss?
ANAESTHESIA TEAM REVIEWS: Are there any patient-specific concerns?
NURSING TEAM REVIEWS: Has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns?
Has antibiotic prophylaxis been given within the last 60 minutes?
Is essential imaging displayed?

Before patient leaves operating room

Sign Out

Nurse verbally confirms with the team:
The name of the procedure recorded
That instrument, sponge, and needle counts are correct (or not applicable)
How the specimen is labeled (including patient name)
Whether there are any equipment problems to be addressed
The surgeon, anesthesia professional, and nurse review the key concerns for recovery and management of this patient


Signature (on behalf of the entire team)
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