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WHO Surgical Safety Checklist Template

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WHO Surgical Safety Checklist Template

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Before induction of anaesthesia

Sign In

Patient has confirmed:

Identity

Site

Procedure

Consent

Site marked/not applicable

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 confirmPatientSite Procedure

ANTICIPATED CRITICAL EVENTS

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

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