Surgical Safety Checklist
Patient’s Name: _______________________________ Date: ___________________________________________
Age: ________________________________________ Time: ___________________________________________
Pre-Op Diagnosis: _____________________________ Case No.: ________________________________________
____________________________________________ Surgeon: _________________________________________
____________________________________________ Anesthesiologist: __________________________________
____________________________________________ First Surgical Asst.: ________________________________
Before Induction of Anesthesia Before Skin Incision Before Patient Leaves OR
Sign In Time Out Sign Out
Patient has confirmed. Confirm all team members have Nurse verbally confirms with the
Identify introduced themselves by name and team:
Site role. The name of the procedure
Procedure _____________________________ recorded
Consent _____________________________ ______________________________
____________________________ _____________________________ ______________________________
Site Marked/Not Applicable ______________________________
____________________________ Surgeon, Anesthesia Professional That instrument, sponge and
Pulse Oximeter on Patient and and Nurse verbally confirm. needle counts are correct.
Functioning Patient ______________________________
____________________________ Site ______________________________
Precaution
Does a patient have any known How the specimen is labeled
allergies? Anticipated Critical Events (including the patient’s name)
______________________________
Yes _____________________________ ______________________________
No Surgeon reviews: What are the ______________________________
_____________________________ critical or unexpected steps, operative
_____________________________ duration, anticipated blood loss? Whether there are any instrument
_____________________________ _____________________________ problems to be addressed
_____________________________ ______________________________
Difficulty Airway/ Aspiration Risk Anesthesia Team Reviews: Are ______________________________
there any patient-specific concern? ______________________________
Yes, and equipment/assistance. _____________________________
No _____________________________ Surgeon, anesthesia professional
_____________________________ and nurse review the key concerns for
_____________________________ Nursing Team Reviews: recovery and management of this
_____________________________ patient.
Has Sterility including indicator
Risk of >500ml Blood Loss results been confirmed?_____ Are ______________________________
(7ml/kg in Children) there equipment issues or any ______________________________
concern? ______________________________
Yes, and adequate intravenous _____________________________
access and fluids planned. _____________________________
No
Has antibiotic prophylaxis been given
____________________________ within the last 60 minutes?
____________________________
Yes
Not applicable
Is essential imaging displayed?
Yes
Not applicable
