Patient Name: _________________________

File No.: ______________________________ KING ABDULAZIZ UNIVERSITY HOSPITAL

Procedure: ____________________________ SURGICAL SAFETY CHECKLIST
Date: ________________________________

Before Induction of Anesthesia – SIGN IN Before Skin Incision – TIME OUT Before Patient Leaves OR – SIGN OUT

NURSE NURSE, ANESTHETIST & NURSE, ANESTHETIST & SURGEON

Has the patient confirmed his / her SURGEON Nurse Verbally Confirms:
identity, site procedure and consent? Confirm all team members have The name of the procedure
YES introduced themselves by name Completion of instrument
Is the site marked? & role. Sponge & needle counts, specimen
YES Confirm the patient’s name, labeling (read specimen labels aloud
NO procedure & where the incision including patient name)
Does the patient have a known allergy? be made. Whether there are any equipment
YES SURGEON: problems to be addressed.
NO If antibiotic prophylaxis is advised and it is YES NO N/A
given within the last 60 minutes?
Anesthetist YES NO N/A
ANESTHETIST:
Is the anesthesia machine and Anticipated Critical Events to What are the key concerns for recovery
medication check complete? Surgeon: and management of this patient in
YES Critical events anticipated or not
recovery room?
NO including length of surgery
Difficulty airway or aspiration risk? Routine
YES NO N/A
YES Anticipated blood loss Special
NO YES NO N/A
YES, and equipment / assistance
Available risk of >500ml blood loss To Nursing Team
(7kg in children) Has sterility (including Signature:
Does the patient have a known allergy? indicators results) been
Anesthetist:____________________
NO confirmed?
Nurse (Circulating)______________
YES & two IV’s/central access & Are there equipment issues or any
fluids planned concerns? Surgeon:________________________
Are there any patient specific YES NO
concerns?
Is essential imaging
displayed?
YES NO