WHO Surgical Safety Checklist:

for Radiological Interventions ONLY

(adapted from the WHO Surgical Safety Checklist)

SIGN IN (To be read out loud) SIGN OUT (To be read out loud)
Before giving anaesthetic (local or general) Before any member of the team leaves the room
ONLY IF GENERAL
Have all team members introduced themselves by name and role? ANAESTHETIC IS GIVEN Registered Practitioner/HCA verbally confirms with the team:
Yes Has the name and side of the procedure been recorded?
Have all pieces of invasive equipment used been
All team members verbally confirm:
What is the patient’s name? TIME OUT (To be read out loud) accounted for?
Have any implanted devices been recorded?
What procedure, site and position are planned?
Before start of radiological intervention Have the specimens been labelled (including with
If general anaesthetic given the two questions above should (for example needle to skin) patient’s name)?
be moved to the beginning of TIME OUT Have any equipment problems been identified that need
Anticipated critical events
to be addressed?
Has the patient confirmed his/her identity, site, procedure and consent?
Anaesthetist (if present):
Yes Radiologist, Anaesthetist and Registered Practitioner:
Is the anaesthetic machine check complete?
Have the instructions for post procedural care for this
Has essential imaging been reviewed?
Does the patient have a difficult airway/aspiration risk? patient been agreed?
Yes N/A
Yes N/A
Are all IRMER requirements met? Remember to scan onto CRIS
Are there any patient-specific concerns? or record checklist has been undertaken
Yes
What is the patient’s ASA grade?
Is the procedural site marked? What monitoring equipment and other specific levels of
PATIENT DETAILS
Yes N/A support are required, for example blood?
Is the anaesthesia machine/monitoring equipment and Registered practitioner/HCA: Last name:
medication check complete? Are there any equipment issues or concerns?
Yes N/A First name:
Has the surgical site infection (SSI) bundle been undertaken?
Does the patient have a: Yes N/A Date of birth:
known allergy? • Antibiotic prophylaxis
No Yes NHS Number:*
• Patient warming
anticipated risk of >500ml blood loss (7ml/kg in children)? • Hair removal Date of Procedure:
No Yes (and adequate IV access/fluids planned) • Glycaemic control *If the NHS Number is not immediately available, a temporary number should be used until it is
Have risk factors for bleeding and renal failure been checked?
Yes N/A
Has Antibiotic prophylaxis been given? The checklist is for
Yes N/A
Has VTE prophylaxis been undertaken?
Radiology Interventions only
Yes N/A This modified checklist must not be used for other surgical procedures.

Is the required equipment available and in date?

Yes www.nrls.npsa.nhs.uk
Are there any critical or unexpected steps you want the team © National Patient Safety Agency 2010. Copyright and other intellectual
to know about? property rights in this material belong to the NPSA and all rights are
reserved. The NPSA authorises UK healthcare organisations to reproduce
Yes N/A this material for educational and non-commercial use.

Ref: 1121 March 2010