SURGICAL SAFETY CHECKLIST

Good morning / afternoon / evening Doctors and Nurses! Today is March 27, 2024. Our
patient is Name, age, from address, scheduled for procedure.

SIGN IN (before induction of anesthesia)

 Excuse me Doctors and Nurses, ready for sign in.

 Our patient’s name is Name of patient. The site is area. The procedure is procedure.
Consent for procedure and anesthesia induction secured signed by who signed the
consent.
 Doctor Name of Surgeon, is the site marked?
 Doctor Name of Anesthesiologist, is the anesthesia safety check complete?
 The pulse oximeter on the patient is connected and functioning.
 The patient has no known allergy. *The patient has an allergy to specify what.
 Doctor Name of Anesthesiologist, is there an airway difficulty? Risk for aspiration?
 Doctor Name of Surgeon, is there a risk for > 5oo ml blood loss?
 Thank you Doctors and Nurses, sign in complete.

TIME OUT (before skin incision)

 Excuse me Doctors and Nurses, ready for time out.

 Surgical team members, please introduce yourself by name and by role.
 Doctor Name of Surgeon kindly verbally confirm the patient’s name, the site, and the
procedure.
 Doctor Name of Surgeon, what are the critical or unexpected steps? Operative
duration? Anticipate blood loss?
 Doctor Name of Anesthesiologist, are there any patient-specific concerns?
 Ma’am / Sir Name of Scrub Nurse, has sterility been confirmed? Are there any
equipment issues or concerns?
 Name of antibiotic was given within 60 minutes. *Name of antibiotic started.
 X-Ray / CT scan / MRI films displayed. *esp. for cranio and ortho.
 Thank you Doctors and Nurses, time out complete.

SIGN OUT (before patient leaves OR theater)

 Excuse me Doctors and Nurses, ready for sign out.

 The name of the procedure is procedure.
 All instruments, sponges, and needles are complete and counted.
 The specimen is labeled left / right name of specimen.
 Doctor Name of Surgeon and Doctor Name of Anesthesiologist, are there any
equipment problems to be addressed?
 Doctor Name of Surgeon, Doctor Name of Anesthesiologist, and nurses, are there
any key concerns for the recovery and management of the patient?
 Thank you Doctors and Nurses, sign out complete.