Sululta Health Center Surgical Safety Checklist

(Adopted from WHO safety Checklist)

Patient/client Name-------------------------------- Sex-------Age--------MRN--------------------
Date---------------------- Starting time………... End time..………..
Before induction of anesthesia (sign in) Before skin incision (time out) Before patient leaves room (sign out)
(with at least nurse and anesthetist) (with nurse, anesthetist and surgeon) (with nurse, anesthetist and surgeon)
Has the patient confirmed his/ her identity, site,  Type of procedure----------------------------------- Nurse verbally confirms:
procedure and consent?  Indication for procedure-----------------------------
 Yes No  Procedure performed……………………………...
 Confirm all team members have introduced
Is the site marked?  Count of instrument, sponge and needle correct?
themselves by name and role---------
 Yes  Confirm the patients name, procedure, consent and Yes
 No Not applicable where the incision will be made.  No
Is the anesthesia machine and medication check complete? Yes
If No, remark__________________________
 Yes No
 Has antibiotics been within the last 60 minutes?  Is the specimen labeled correctly?
 No
 Yes
Is the pulse oximeter on the patient and functioning?  Yes
 No Not applicable
 Yes  No
 No Anticipated critical events to
 Not applicable
Does the patient have known allergies? Surgeon/Gynaec./IESO:  Were there equipment problems?
 No  What are the critical or non-routine steps?---------  No
 Yes --------------------------------------------------------  Yes__________________________
 Un known  How long will the case take?---------------------
Does the patient have a difficult airway or aspiration risk?  What is the anticipated blood loss? ------------- To surgeon, Anesthetist and nurse:
 No To Anesthetist and surgeon:  What are the key concerns for recovery and management
 Yes, equipment and /assistant available  Is there any patient focus concern? of this patient? ________________________________
 No _______________________________________
Risk of > 500ml blood loss (7ml/kg in children)?
 Yes …………………………………..  Procedure Team Members
 No Surgeon………………………………………
 Yes, and two IVs/central access and fluids To nursing team:
 Has sterility (including indicator results) been Anesthetist……………………………………
confirmed?  Yes No Assistant …………………………………….
 Are there equipment issues or any concern? Scrub nurse………………………………….
 No Circulating nurse…………………………….
 Yes-------------------------------------
Check list filled by…………………………..Sign………...