7/23/2019 WHO Checklist Word V3

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WHO Surgical Safety Checklist

Instructions

Local adaptation of this Checklist is encouraged to ensure it is effectively integrated into clinical

practice. This may mean that some of the interventions are moved to a different step in theChecklist, for example from Time Out to Sign n.

Some interventions may also !e moved to the "reoperative team !rief.

Any adaptations should be undertaken in accordance with your organisation's governancescrutiny process.

This checklist contains the core content for #ngland and $ales

7/23/2019 WHO Checklist Word V3

2/2

WHO Surgical Safety Checklist

SI! I! "to be read out loud#$efore induction on anaesthesiaHas the patient confir%ed his&her identitysite procedure and consent(% &es

Is the surgical site %arked(% &es'not applica!le

Is the anaesthesia %achine and %edicationcheck co%plete(% &es

)oes the patient have a*+nown allergy(% (o% &es)ifficult airway&aspiration risk(% (o% &es, and e)uipment'assistance availa!le,isk of -//%l blood loss "0%l&kg in

children#(% (o% &es, and ade)uate * access'fluids planned

1A2I3!2 )32AI4S

Last name+

irst name+

-ate of !irth+

(S (um!er/+

"rocedure+/f the (S (um!er is not immediately availa!le, a temporarynum!er should !e used until it is

2I53 O62 "to be read out load#

$efore start of surgical interventionfor example, skin incision

Have all tea% %e%bers introduced the%selvesby na%e and role(% &es

Surgeon Anaesthetist and ,egistered1ractitioner verbally confir%*% $hat is the patients name0% $hat procedure, site and position are planned0Anticipated critical eventsSurgeon*% o1 much !lood loss is anticipated0% 2re there are specific e)uipment re)uirements

or special investigations0% 2re there any critical or unexpected steps you

1ant the team to kno1 a!out0Anaesthetist*% 2re there any patient specific concerns0% $hat is the patients 2S2 grade0

% $hat monitoring e)uipment and other specificlevels of support are re)uired, for example!lood0

!urse&O)1*% as the sterility of the instrumentation !een

confirmed 3including indicator results40% 2re there are e)uipment issues or concerns0

Has the surgical site infection "SSI# bundle beenundertaken(% &es'not applica!le

o 2nti!iotic prophylaxis 1ithin the last 56

minuteso "atient 1arming

o air removalo 7lycaemic control

Has 723 prophyla8is been undertaken(% &es'not applica!le

Is essential i%aging displayed(% &es'not applica!le

(ame+

Signature of8egistered "ractitioner+

SI! O62 "to be read out loud#

$efore any %e%ber of the tea% leaves theoperating roo%,egistered 1ractitioner verbally confir%s withthe tea%*% as the name of the procedure !een recorded0

% as it !een confirmed that instruments, s1a!sand sharp counts are complete 3or notapplica!le40

% ave the specimens !een la!eled 3includingpatient name40

% ave any e)uipment pro!lems !een identifiedthat need to !e addressed0

Surgeon Anaesthetist and ,egistered1ractitioner*% $hat are the key concerns for recovery and

management of this patient0

(ame+

Signature of8egistered "ractitioner+

This checklist contains the core content for #ngland and $ales