DIVINE MERCY HOSPITAL

MC ARTHUR HI-WAY, BAMBAN, TARLAC

TEL. NO. (O45)493-0066

NAME____________________________________________CASE NUMBER____________DATE_______
AGE___________ SEX________CIVIL STATUS___________ROOM NO._______________
ATTENDING PHYSICIAN_____________________________
ANESTHESIOLOGIST________________________________

SURGICAL SAFETY CHECKLIST

(Adopted from WHO)

BEFORE INDUCTION OF ANESTHESIA BEFORE SKIN INCISION BEFORE PATIENT LEAVES

OPERATING ROOM
SIGN IN TIME OUT SIGN OUT
Patient has confirmed Confirm all team members have introduced Nurse Verbally confirms with the
• Identity themselves by name and role team:
• Site
• Procedure The name of the procedure record
• Consent ________________________
________________________
That instruments, sponge and
needle counts are correct (or not
applicable)

How the specimen labeled

( including the patient name)
________________________
________________________
Site marked Surgeon, Anesthesia professional and Nurse Whether there are any equipment
Not applicable Verbally Confirm problems to be addressed
________________________
• Patient
________________________
• Site
Surgeon, anesthesia Professional
• Procedure
and Nurse review the key concern
for recovery and management of
the patient
Anesthesia safety check completed Anticipated Critical Events:
Surgeon Reviews: What are the critical or unexpected
steps, operative duration, anticipated blood lost?
Remarks:_________________________
_______________________________
Anesthesia Team Reviews: Are there any patient-
specific concerns?
Remarks____________________________
_________________________________
Nursing Team Reviews: has sterility (including indicator
results) been confirmed? Are there equipment issues or
any concerns?
Remarks____________________________
__________________________________

Pulse oximeter on patient and Has antibiotic prophylaxis been given within the last
functioning 60 minutes?
Yes
Not applicable

Is essential imaging displayed?

Yes
Not applicable
Does patient have:
KNOWN ALLERGY
No
Yes

DIFFICULT AIRWAY/ ASPIRATION

RISK?
No
Yes and equipment/assistance
available

RISK OF >500 ML BLOOD LOSS

(7Ml/Kg in Children)
No
Yes and adequate intravenous access
and fluids planned