Safe Surgery Checklist template Hospital Name

Before Induction of Anesthesia Before Skin Incision Before Patient Leaves Room
Nurse and Anesthesia Professional verify: TIME OUT Nurse reviews with team:
Patient identification (name and DOB) Circulating Nurse asks: Instrument, sponge, and needle counts
Surgical site “Is everyone ready to perform the time out? Name of the procedure performed
Surgical procedure to be performed Please state your name and role.” Nurse reads aloud to team:
matches the consent Specimen labeling, including patient’s name
Entire Surgical Team confirms:
Site marked
Patient name TEAM DEBRIEFING
Known allergies
Surgical procedure to be performed Entire Surgical Team discusses:
Patient positioning
Surgical site Key concerns for patient recovery and
Essential imaging available
Essential imaging available management
Risk of hypothermia (if operation >1 hour)
Antibiotic prophylaxis given within the last Equipment problems that need to be
• Warmer in place 60 minutes addressed
Risk of venous thromboembolism
• Antibiotic redosing plan discussed Other opportunities for improvement
• Boots in place and/or anticoagulants
Anesthesia safety check completed TEAM BRIEFING
Surgeon shares:
ANESTHESIA BRIEFING
Operative plan
Anesthesia Professional shares:
Possible difficulties
Anticipated airway or aspiration risk
Expected duration
Risk of significant blood loss
Anticipated blood loss
• Two IVs/central access and fluids planned
Implants or special equipment needed
• Type and crossmatch/screen
• Blood availability Anesthesia Professional shares:
Anesthetic plan
Airway concerns
Other concerns
Circulating Nurse and Scrub Tech share:
Sterility, including indicator results
Equipment issues
Other concerns

Surgeon asks:
“Does anybody have any concerns?
If you see something that concerns you
during this case, please speak up.”

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. Based on the WHO Surgical Safety Checklist (http://www.who.int/patientsafety/safesurgery/en)
© 2008 World Health Organization All rights reserved. SSC-Master template Revised: 7 August 2015