Safe Surgery Checklist template

This version of the Safe Surgery Checklist template is intended for facilities in which the Before Induction steps are performed in the
preoperative area and the Before Incision and Before Patient Leaves Room sections are performed in the operating/procedure room.
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
Based on the WHO Surgical Safety Checklist (http://www.who.int/patientsafety/safesurgery/en)
2008 World Health Organization All rights reserved.

SSC-2page.1 Revised: 7 August 2015

Hospital Name

Safe Surgery Checklist template

Hospital Name

Before Skin Incision

Before Induction of
TIME OUT
Anesthesia

Circulating Nurse asks:

Nurse and Anesthesia
Is everyone ready to perform the time out?
Professional verify:
Please state your name and role.
Patient identification (name
and DOB)
Entire Surgical Team confirms:
Surgical site
Patient name
Surgical procedure
to be procedure to be performed
Surgical
performed matches
the
Surgical
site
consent
Essential imaging available
Site marked
Antibiotic prophylaxis given within the last
Known allergies
60 minutes
Patient positioning
Antibiotic redosing plan discussed
Essential imaging available
TEAM
BRIEFING
Risk of hypothermia
(if
operation >1 hour)
Surgeon shares:
Warmer inplace
Operative plan
Risk of venous Possible difficulties

thromboembolism
Expected duration
Boots in place
and/or
Anticipated blood loss
anticoagulants
Implants or special equipment needed
Anesthesia safety check
completed
Anesthesia Professional shares:
Anesthetic plan
ANESTHESIA BRIEFING
Airway concerns
Anesthesia Professional

shares:

Other concerns

Anticipated airway or
Circulating Nurse and Scrub Tech share:

aspiration risk

Sterility, including indicator results

Risk of significant blood
Equipment issues
loss

Other concerns
Two IVs/central
access and fluids
planned Surgeon asks:
Type and Does anybody have any concerns?
If you see something that concerns you
crossmatch/screen
during this case, please speak up.
Blood availability

This version of the Safe Surgery Checklist template is intended for facilities in which the Before Induction steps are performed in the
preoperative area and the Before Incision and Before Patient Leaves Room sections are performed in the operating/procedure room.
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
Based on the WHO Surgical Safety Checklist (http://www.who.int/patientsafety/safesurgery/en)
2008 World Health Organization All rights reserved.

SSC-2page.2 Revised: 7 August 2015

Safe Surgery Checklist template

Before Patient Leaves Room

Hospital Name

Before Patient Leaves Room

Nurse reviews with team:

Instrument, sponge, and needle counts

Entire Surgical Team discusses:

Key concerns for patient recovery and management

Name of the procedure performed

Equipment problems that need to be addressed

Nurse reads aloud to team:

Specimen labeling, including patient's name

Other opportunities for improvement

TEAM DEBRIEFING

This version of the Safe Surgery Checklist template is intended for facilities in which the Before Induction steps are performed in the
preoperative area and the Before Incision and Before Patient Leaves Room sections are performed in the operating/procedure room.
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
Based on the WHO Surgical Safety Checklist (http://www.who.int/patientsafety/safesurgery/en)
2008 World Health Organization All rights reserved.

SSC-2page.2 Revised: 7 August 2015