Surgical Safety Procedure Checklist
Accreditation Programs/Settings: CAH, HAP, OBS
Surgical Safety Procedure Checklist
This checklist lists the steps to take to help ensure safe surgery in the operating room (OR). It’s adapted from the
Safe Surgery Checklist created by the World Health Organization (WHO). You can use it in the OR for every surgery
and add a copy to the patient’s medical record.
Organization: __________________________________________________________________________
Date of Review: _____________ Reviewer: __________________________________________________
Patient Medical Record #: _______________________________
Step Action [CAH, HAP, OBS] N/A
Before Anesthesia (with nurse and anesthetist)
1 Verify the patient’s confirmation of his/her identity, consent, and surgical site and procedure.
2 Verify that the site is marked.
3 Verify that the anesthesia machine and medication check is complete.
4 Verify that the pulse oximeter is on the patient and is functioning.
5 Check to see if the patient has a known allergy.
6 Check to see if the patient has a difficult airway or aspiration risk.
IF YES, check that equipment/assistance is available.
7 Check to see if the patient has a risk of >500 ml blood loss (7ml/kg in children).
IF YES, check that two IVs/central access and fluids are planned.
Before Skin Incision (with nurse, anesthetist, and surgeon)
6 Confirm that all team members have introduced themselves by name and role.
7 Confirm the patient’s name, surgical procedure, and incision site.
8 Verify that antibiotic prophylaxis been given within the last 60 minutes.
9 Anticipate critical events:
Ask the surgeon about critical or nonroutine steps, how long the case will take, and if there
is any anticipated blood loss.
Ask the anesthetist if there are any patient-specific concerns.
Ask the nursing team if sterility (including indicator results) has been confirmed, and if
there are any equipment issues or any other concerns.
10 Verify that essential imaging is displayed.
Before Patient Leaves OR (with nurse, anesthetist, and surgeon)
11 Nurse: Verbally confirm the name of the procedure, completion of counts (instruments,
sponges and needles), specimen labelling (read specimen labels aloud, including patient
name), and whether there are any equipment problems to be addressed.
12 Nurse, anesthetist, and surgeon: Share key concerns for recovery of the patient.
© 2016 The Joint Commission. May be adapted for internal use. Page 1 of 1
