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WHO Surgical Safety Checklist

Purpose: To utilize the WHO surgical safety checklist to improve patient surgery during an operative procedure.

Evaluation

Are you performing a surgical procedure on a paient?

Age of the patient

years

Body weight

Expected blood loss

mL

Select the appropriate answer for each sign in item

Patient confirmed identity

Procedure and surgical site confirmed

Consent granted and documented

Surgical site marked

Anesethesia equipment checked

Anesthesia medications checked

Allergies documented

Ready for a difficult airway

Pulse oximeter working properly

Select the appropriate answer for each time out item

Team members introduced

Patient's name confirmed

Procedure, site and position confirmed

Expected blood loss reported

Special supplies available

Expected length of the procedure stated

Critical or unexpected steps announced

Patient specifiic concerns listed

ASA grade

Monitoring equipment available

Blood and other support items available

Sterility of supplies confirmed

Equipment concerns specified

Antibiotic prophylaxis within last hour

Patient warming available if needed

Hair removal and skin prep performed

Steps taken to maintain glycemic control

Venous thromboembolism prophylaxis

Essential imaging displayed

Select the appropriate answer for each sign out item

Name of procedure recorded

Instrument, sponge, sharp counts right

Specimens properly labeled

Equipment problems identified

Recovery or management concerns

Results

Please fill out required fields.

Specialty

Objective

ICD-10