SURGICAL SAFETY CHECKLIST

PRE-PROCEDURE
SIGN-IN TIME-OUT SIGN-OUT
CHECK-IN
Before Induction of Before the Patient Leaves
In Preoperative Ready Area Before Skin Incision
Anesthesia the Operating Room
Patient or patient
representative actively Initiated by designated team
RN and anesthetist confirm RN confirms
confirms with the registered member
nurse (RN)

Identity  Yes Confirmation of the following: Introduction of team members Name of operative procedure:
identity, procedure site/side and  Yes __________________________
Procedure & the site/side  Yes consent(s)  Yes All: __________________________
Confirmation of the following:
Consent(s)  Yes Site/side marked by the surgeon identity, procedure site/side and Completion of sponge, sharp,
performing the procedure consent(s)  Yes and instrument counts
Site/side marked by the surgeon  Yes  N/A  Yes  N/A
performing the procedure Site is marked and visible
 Yes  N/A Patient allergies  Yes  N/A Specimen identified and labeled
 Yes  N/A  Yes  N/A
RN confirms presence of: Fire Risk Assessment & Discussion
History and physical  Yes Pulse oximeter on patient  Yes (prevention methods Equipment problems to be
 Yes implemented) addressed
Preanesthesia assessment  Yes  N/A  Yes  N/A
Difficult airway or aspiration risk
Nursing Assessment  Yes  No Relevant images properly labeled Discussion of wound
 Yes (preparation confirmed) and displayed  Yes  N/A classification  Yes
Diagnostic & radiologic test results
 Yes  N/A Risk of blood loss (>500 mL) Anticipated Critical Events To all team members:
 Yes  N/A What are the key concerns for
Blood Products Surgeon: States the following: recovery and management of
 Yes  N/A # of Units Available ____________  Critical or non-routine steps this patient?
 Case duration __________________________
Any special equipment, devices, Anesthesia safety check  Anticipated blood loss __________________________
implants  Yes  N/A completed?  Yes __________________________
Anesthetist:
Beta blocker medication given Briefing: Antibiotic prophylaxis within 1 hour Debriefing with all team
 Yes  N/A All members of the team have before incision  Yes  N/A members:
discussed care plan and Additional concerns Yes  N/A Opportunity for discussion of
VTE prophylaxis ordered addressed concerns  Yes  team performance
 Yes  N/A Scrub person and RN circulator:  key events
Sterilization confirmed  Yes  any permanent changes in
Normothermia measures Additional concerns Yes  N/A the preference card
 Yes  N/A
RN:
Documented completion of time out
 Yes
 INTERNATIONAL PATIENT
SAFETY GOALS
IPSG 1: Identify Patient Correctly.

IPSG 2: Improve Effective Communication.

IPSG 3: Improve Safety of High Alert

Medication.

IPSG 4: Ensure Correct Site, Procedure, and

Patient Surgery.

IPSG 5: Reduce the Risk of Health-Care

Associated Infections.

IPSG 6: Reduce Patient Falls.