World Health Organization Surgical Safety Checklist

Has the patient confirmed his/her identity, site, procedure, and consent?

• Yes
• No
• N / A

Is the site marked?

• Yes
• No
• N / A

Is the anaesthesia machine and medication check complete?

• Yes
• No
• N / A

Is the pulse oximeter on the patient and functioning?

• Yes
• No
• N / A

Does the patient have a:

• Known allergy?

• Difficult airway or aspiration risk?

• Risk of >500ml blood loss (7ml/kg in children)?

Before skin incision

• Confirm all team members have introduced themselves by name and role

• Confirm the patient's name, procedure, and where the incision will be made

• Had antibiotic prophylaxis have been given within the last 60 minutes?

What are the critical or non-routine steps?

How long will the case take?

What is the anticipated blood loss?

Are there any patient specific concerns?

• Yes
• No
• N / A

Has sterility (including indicator results) been confirmed?

• Yes
• No
• N / A

Are there equipment issues or any concerns?

• Yes
• No
• N / A

Is essential imaging displayed?

• Yes
• No
• N / A

The name of the procedure?

• Yes
• No
• N / A

Completion of instrument, sponge and needle counts

• Yes
• No
• N / A

Specimen labelling (read specimen labels aloud, including patient name)

• Yes
• No
• N / A

Whether there are any equipment problems to be addressed

• Yes
• No
• N / A

Are there any key concerns for recovery and management of this patient?

• Yes
• No
• N / A

Surgeons Full Name:

Surgeons Signature