WHO Surgical Safety Checklist

WHO Surgical Safety Checklist **Date:** 01 November 2024 **Patient Name:** John Smith **Hospital Number:** 1234567 **Procedure:** Appendectomy **Surgeon:** Dr. Emily Carter **Anesthetist:** Dr. David Lee **Nurse:** Sarah Jones **Team Introduction (Sign-in)** * **Confirm patient:** John Smith, DOB: 01/01/1980 * **Confirm procedure:** Appendectomy * **Confirm consent:** Consent form signed and in chart. * **Mark surgical site:** Site marked and verified. * **Anesthesia safety check:** Complete and documented. * **Pulse oximeter on patient and functioning:** Yes * **Known allergies:** No known allergies. * **Difficult airway/aspiration risk:** No anticipated difficulties. * **Risk of blood loss:** Minimal risk. **Time Out (Before Skin Incision)** * **Confirm all team members have introduced themselves by name and role:** Yes, all team members have introduced themselves. * **Surgeon confirms patient, procedure, and site:** Confirmed. * **Anesthetist confirms patient-specific concerns:** No concerns. * **Nurse confirms sterility, equipment, and any concerns:** All equipment is sterile and ready. No concerns. * **Antibiotic prophylaxis administered within the last 60 minutes:** Yes, Cefazolin administered. * **Essential imaging displayed:** Not applicable. **Sign Out (Before Patient Leaves Operating Room)** * **Nurse verbally confirms the procedure has been completed:** Procedure completed. * **Nurse confirms instrument, sponge, and needle counts are correct:** Counts correct. * **Surgeon, anesthetist, and nurse review the recovery and management of the patient:** Plan discussed and agreed upon. * **Label specimens:** Specimens labeled and sent to pathology. * **Any equipment problems to be addressed:** None.