Republic of the Philippines

Province of Ilocos Sur

ILOCOS SUR PROVINCIAL HOSPITAL-GABRIELA SILANG
Vigan City
WHO Surgical Safety Checklist

DATE & TIME: ___________________________________________WARD/ROOM: ____________________

PATIENT’S NAME: _________________________________ AGE: ________ HOSP. NO. ________________

Before Induction on Before Skin Incision Before Patient leaves

Anesthesia
Has the patient confirmed
his/her identity, site, procedure,
and consent?
Yes
Is the site marked?
Yes
Not applicable
Is the anesthesia machine and
medication check complete?
Yes
Is the pulse oximeter on the
patient functioning?
Yes
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
fluid planned
Operating Room
Confirm all team members have Nurse verbally confirms:
introduces themselves by name The name of the procedure
and role. Completion of instruments,
sponge and needle counts
Confirm the patient’s name,
procedure, and where the Specimen labelling (read
incision will be made. specimen labels aloud
including patient name)
Has antibiotic prophylaxis been
Whether there are any
given within the last 60 mins?
Yes equipment problems to be
Not applicable addressed?
Surgeon, Anesthesiologist and
Anticipated critical events
Surgeon: Nurse:
What are the critical or non- What are the key concerns
routine steps? for recovery and
How long will the case take? management of this patient?
What is the anticipated blood
loss?
Anesthesiologist:
Are there any patient specific
concerns?
To Nursing Team:
Has the sterility been
confirmed (including
indicator results)?
Are there equipment issues or
any concerns?
Is essential imaging displayed?
Yes
Not applicable

Prepared by:
____________________________
Nurse-In-Charge

Noted by:
____________________________
Anesthesiologist

_______________________________
Surgeon