Operating Theatre Surgical Safety Checklist
Patient No:
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Sex
Male
Female
Operation
Time patient was received
Pre-procedure checklist
Has consent for surgery been obtained?
Yes
No
Has the site been marked?
Yes
No
Has the site of the operation been prepared?
Yes
No
Is the pre-operative checklist complete?
Yes
No
Comprehensive history & physical examination performed?
Yes
No
Has a pre-anaesthetic assessment been completed?
Yes
No
Not applicable
Have diagnostic & radiological test results been reviewed?
Yes
No
Not applicable
Are blood products available?
Yes
No
Are any implants or special equipment required?
Yes
No
Has all nail polish, contact lenses, dentures and jewelry been removed?
Yes
No
Not applicable
Time of last meal
Hour Minutes
AM
PM
AM/PM Option
Time of last voiding
Hour Minutes
AM
PM
AM/PM Option
Is the patient on any special medication?
Yes
No
If so, then please specify?
Any known allergies?
Yes
No
Any intravenous access line?
Yes
No
Is a catheter insitu?
Yes
No
Have vital signs been recorded?
Yes
No
Has any pre-medication been given?
Yes
No
If so, then please specify?
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BEFORE INDUCTION OF ANAESTHESIA
Is the anaesthesia safety check complete?
Yes
No
Is the pulse oximeter on the patient functioning?
Yes
No
Does the patient have any known allergies?
Yes
No
Is there a risk of blood loss greater than 500mls?
Yes
No
Is there any difficulty with the patient's airways or aspiration rate?
Yes
No
Preparation for blood loss/difficulty airway confirmed?
Yes
No
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TIME-OUT
Before Skin Incision
Expected length of procedure
Critical or non-critical steps
Anticipated blood loss
Start Time
Questions
Rows
Yes
No
Not applicable
Confirmed patient's name, procedure and incision site?
Any specific concerns for the procedure stated?
Have anti-biotics been given within the last 60 minutes?
Any specific patient concerns?
Are blood products available for surgery?
Has sterility been confirmed?
Have initial swap counts been done?
Any equipment or staffing concerns?
Is the diathermy machine functioning and pad in place?
Is essential imaging displayed?
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SIGN-OUT
Before the patient leaves the operating room
End Time
Name of the procedure
Has the tourniquet been removed?
Yes
No
Are the instruments complete? Including swabs, sponges and needle count?
Yes
No
Has any specimen been labelled?
Yes
No
Not applicable
Is there any equipment problem to address?
Has the throat pack been removed?
Yes
No
What are the key concerns for the recovery and management of the patient?
Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: