EASTERN VISAYAS REGIONAL MEDICAL CENTER

Tacloban City, Philippines, 6500

evrmcmccoffice@gmail.com

WHO SURGICAL SAFETY CHECKLIST

PRIOR TO INDUCTION OF ANESTHESIA PRIOR TO SKIN INCISION PRIOR TO PATIENT LEAVING THE OPERATING THEATER

SIGN IN TIME OUT SIGN OUT

 PATIENT HAS CONFIRMED  CONFIRM ALL TEAM MEMBERS HAVE NURSE VERBALLY CONFIRMS WITH THE
• IDENTITY INTRODUCED THEMSELVES BY NAME AND TEAM:
• SITE ROLE  THE NAME OF THE PROCEDURE RECORDED
• PROCEDURE  SURGEON, ANAESTHESIA PROFESSIONAL  THAT INSTRUMENT, SPONGE AND NEEDLE
• CONSENT AND NURSE VERBALLY CONFIRM
COUNTS ARE CORRECT (OR NOT APPLICABLE)
• PATIENT
 HOW THE SPECIMEN IS LABELLED
 SITE MARKED/NOT APPLICABLE • SITE
• PROCEDURE (INCLUDING PATIENT NAME)
 ANAESTHESIA SAFETY CHECK COMPLETED • POSITION  WHETHER THERE ARE ANY EQUIPMENT
 CARDIAC PULSE OXIMETER ON PATIENT AND PROBLEMS TO BE ADDRESSED
FUNCTIONING ANTICIPATED CRITICAL EVENTS  SURGEON, ANAESTHESIA PROFESSIONAL
 NPO _______________  SURGEON REVIEWS: WHAT ARE THE AND NURSE REVIEW THE KEY CONCERNS
DOES PATIENT HAVE A: CRITICAL OR UNEXPECTED STEPS,
FOR RECOVERY AND MANAGEMENT
KNOWN ALLERGY? OPERATIVE DURATION, ANTICIPATED
BLOOD LOSS? OF THIS PATIENT?
 NO
 YES _________________  ANAESTHESIA TEAM REVIEWS: ARE THERE
DIFFICULT AIRWAY/ASPIRATION RISK? ANY PATIENT-SPECIFIC CONCERNS?
 NURSING TEAM REVIEWS: HAS STERILITY SIGNATURE:
 NO
 YES, AND EQUIPMENT/ASSISTANCE (INCLUDING INDICATOR RESULTS) BEEN
CONFIRMED? ARE THERE EQUIPMENT SURGEON: _____________________________________
AVAILABLE
RISK OF >500ML BLOOD LOSS ISSUES OR ANY CONCERNS?
ANESTHESIOLOGIST: _____________________________
(7ML/KG IN CHILDREN)? HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN
 NO WITHIN THE LAST 60 MINUTES?
CIRCULATING NURSE: ____________________________
 YES, AND ADEQUATE INTRAVENOUS ACCESS  YES _______________________________
AND FLUIDS PLANNED  NOT APPLICABLE
IS ESSENTIAL IMAGING DISPLAYED?
 YES _______________________________ DATE: ______________________________
 NOT APPLICABLE WHOSSC-OCN
PATIENT’S NAME: _______________________________ Page 1 of 1
 OTHER CHECKS _________________ 17-September-2018
HOSPITAL NO.: _______________________ Rev. 00