WHO SAFE SURGERY CHECKLIST

Case no.________

SIGN IN
➢ Good morning/evening, I am _________________.
(student’s name)
Our patient for this case is _________________, _____ and was
(name of the patient) (age)
scheduled for _____________________________.
(name of the procedure)
➢ We already have the patient’s consent form signed prior to the
operation.
➢ Dr./Dra. _____________________, is the pre-anesthetic
(name of the Anesthesiologist)
evaluation sheet correctly and carefully accomplished? Do we
have all the anesthetic equipment that we will need?
➢ Is there a risk for blood loss greater than 5,000 cc? If there is, do
we have all the alternative IV access in case that we will need to
transfuse blood units or IV fluids?
➢ That will be the end of our Signing in. We may now proceed to
our operation. THANK YOU.
TIME OUT

➢ Are we all set?

➢ Before we begin, I would like to introduce the surgical team
headed by
Our Surgeon___________________ Trans-in to OR_________
Assistant Surgeon______________ Anesthesia time________
Anesthesiologist________________ Cutting time___________
Pediatrician___________________ Operation ended_______
Scrub nurse___________________ Trans-out_____________
Circulating nurse________________
Student scrub nurse_____________
Student circulating nurse__________
➢ Dr./Dra._______________________, are there any critical
(Name of the Surgeon)
phase or steps that you anticipate?

➢ Dr./Dra.______________________, do you have any patient

(Anesthesiologist)
specific concerns?
➢ Ma’am/Sir_____________________, are there any equipments
or instruments that you are concern about?
➢ That would be all for the timing out, we may now continue with
the operation.
SIGN OUT

➢ Good morning/evening once again!

➢ Please feel free to interrupt and correct me for any
inconsistencies.
➢ We have _________________, as the name of the
(name of the procedure)
procedure done.
➢ All sponges, instruments and needles were counted
complete.
➢ The specimen will be labeled with the name of the
patient and name of the specimen as ____________,
to be sent to the laboratory, for biopsy, will be given to
the patient with logbook duly signed.
➢ Ma’am/Sir_________________, are there any
(Scrub nurse)
equipment or instrument problem encountered during
the operation?
➢ That will be the end of our Signing out. Thank you
everyone for participating!