Blue Safety Checklist Surgical Safety

1 Sign In
(Before induction of anaesthesia) 2 Time Out
(Before skin incision) 3 Sign Out
(Before patient leaves operating room)

l Patient has confirmed: l Confirm all team members have introduced Nurse verbally confirms with the team:
Identity themselves by name and role
Site l The name of the procedure recorded
Procedure l Surgeon, anaesthesia professional and
Consent
nurse verbally confirm: l That instrument, sponge and needle
Patient counts are correct (or not applicable)
l Site marked/not applicable Site
Procedure l How the specimen is labelled
l Anaesthesia safety check completed (including patient name)
Anticipated critical events
l Pulse oximeter on patient and functioning l Surgeon reviews: What are the critical or l Whether there are any equipment
unexpected steps, operative duration, problems to be addressed
Does patient have a known allergy?
anticipated blood loss?
l No l Anaesthesia team reviews: Are there any l Surgeon, anaesthesia professional
l Yes patient-specific concerns?
and nurse review the key concerns for
recovery and management of this patient
Difficult airway/aspiration risk? l Nursing team reviews: Has sterility (including
indicator results) been confirmed? Are there
l No equipment issues or any concerns?
l Yes, and equipment /assistance available
Has antibiotic prophylaxis been given within
Risk of >500ml blood loss (7ml/kg in children)? the last 60 minutes?
l No l Yes
l Yes, and adequate intravenous access and l Not applicable
fluids planned
Is essential imaging displayed?

l Yes
l Not applicable
Based on the WHO Surgical Safety Checklist, URL http://www.who.int/patientsafety/safesurgery/en, World Health Organization 2008 All rights reserved. More information can be found at:
http://www.who.int/patientsafety/safesurgery/using_checklist/en/index.html.