Surgical Safety Checklist

Surgical Safety Checklist

                                                            

Name of Patient_______________________________________

Age/Sex _______________Ward/Room No ________________

UHID. No./ IPD No. ___________________________________

Name of Surgery ____________________________________

DOA ______________Date of Operation___________________

Before induction on anaesthesia (with at least Nurse & Anaesthetist)	Before start of surgical intervention (with Nurse, Anaesthetist & Surgeon)	Before patient leaves operating room (with Nurse, Anaesthetist & Surgeon)
Has the patient confirmed his/her identity, site, procedure and consent? □     Yes	Have all team members introduced themselves by name and role? □     Yes	Registered Practitioner/ Nurse verbally confirms with the team: □     The name of the procedure? □     Has it been confirmed that instruments, swabs and sharp counts are complete? □     Have the specimens been labeled (including patient name)? □     Have any equipment problems been identified that need to be addressed?
Is the surgical site marked? □     Yes □     Not applicable	Confirm the patient’s name, procedure, and where the incision will be made
Is the anaesthesia machine and medication check complete? □     Yes	Has antibiotic prophylaxis been given with in the last 60 minutes? □     Yes/ Not applicable
Does the patient have a: Known allergy? □     No □     Yes Difficult airway/aspiration risk? □     No □     Yes, and equipment/assistance available Risk of >500ml blood loss (7ml/kg in children)? □     No □     Yes, and adequate IV access/fluids planned	Anticipated critical events Surgeon: □     What are the critical or non-routine steps? □     How long will the case take? □     What is the anticipated blood loss? Anaesthetist: □     Are there any patient specific concerns? Nurse: □     Has sterility including indicators results been confirmed? □     Are there are equipment issues or concerns?	Surgeon, Anaesthetist and Nurse: □     What are the key concerns for recovery and management of this patient?
	Is essential imaging displayed? □     Yes / Not applicable
Nurse Name____________________________ Signature	Nurse Name____________________________ Signature	Nurse Name____________________________ Signature
Anaesthetist Name______________________ Signature	Surgeon’s Name________________________ Signature	Surgeon’s Name________________________ Signature
	Anaesthetist Name______________________ Signature	Anaesthetist Name______________________ Signature