WHO-PCS SAFE SURGERY CHECKLIST IMPLEMENTATION PROGRAM

INDIVIDUAL CASE FORM

1. Patient ID No:
2. Diagnosis:

3. Operation Planned:

4. Operation Performed:

5. Date of Operation (Month-Day-Year): / /2017

6. Was checklist utilized in this case? Yes _____ No _____

If Yes, proceed to item 7

If no, state reason(s) for non-utilization _______________________________

7. Compliance to key process measures: Indicate which of the following process measures were performed in this

Process Measures

Process Measures Done Not Not Applicable or Indicated (for 7.3 &
done 7.5 only)
7.1 patient, site, procedure confirmation Yes
7.2 Airway assessment Yes
7.3 Antibiotic prophylaxis Yes
7.4 Pulse oximetry monitoring Yes
7.5 Double IV access line Yes
7.6 OS and instrument count Yes

8. Checklist Coordinator: Joseph Wincor A Bacus, MD

Name and Signature

9. Date of Discharge: / /2017

10. Adverse Outcomes: Did any adverse event occur? Yes _____ No ____

It yes, proceed

OUTCOME Detail Date

10.1 Complication (infection, etc.)
10.2 Death
10.2.1 on day of surgery (within 24 hours)
10.2.2 In-hospital death (>24 hours but within
hospital confinement)
3. Others