Last Name First Name Middle Name Age Sex

Surgeon Assistant Surgeon Time Started: _________ AM _________ PM

Time Ended: ________ AM ________ PM

Anesthesiologist Anesthesia Induction Time:

Diagnosis Procedure

Scrub Nurse: Circulating Nurse: Pre Meds: Vital Signs: BP ______ PR _____ RR _____

Time Given: Height ______ Weight ______

Specimen: Time Specimen Out: Sent for Histopath:
_______________________________
Given to Patient:_________________
Procedure to Anesthesia Prior To Skin Incision Prior to Patient Leaving the OR Theater

Patient to confirmed Confirm All Team Members Nurse Verbally Confirms to the Team
have introduced Themselves by
 Identify Name and Role The Name of the Procedure
 Site Recorded
 Procedure Surgeon, Anesthesia Professional
 Consent And Nurse Verbally Confirmed That Instrument , Sponge and
Needle Counts are Correct
Site Marked/ Not Applicable  Patient How well the Specimen is
 Procedure Labeled
Pre- Anesthetic Evaluation  Site
 Position  Patient
Sheet Completed  Specimen
Anticipated Critical Events:  Name of SN/CN
Patient Hooked to Pulse Oximeter  Date of Operation
Surgeon Reviews:  Surgeon
Does Patient have the:  What are the critical or
unexpected steps, operative Whether There are Any
 Known Allergy duration, anticipated blood loss Equipment Problems to be
Addressed
YES NO Anesthesia Team Reviews:
 Are there any patient specific Surgeon, Anesthesia
 Difficulty Airway Aspiration Risk? concerns Professional and Nurse Review
The Particular Concerns For
YES and Equipment Assistant Nursing Team Reviews: Recovery And Management of
Available This patient?
NO  Has sterility been confirmed? Are
there equipment issues or any
 Risk of 500cc Blood Loss concerns?
o ( 7cc if children ) Antibiotics Prophylaxis given within
the last 60 minutes
YES and IV Access and Fluids
Planned YES NOT APPLICABLE

Essential Imaging Displayed

_______________________________
YES NOT APPLICABLE Signature over Printed Name
(Anesthesiologist)
OTHERS CHECKS ________________ License No.

Form No.:

Hospital No.:

Case No.:

Room No.:

SURGICAL SAFETY CHECKLIST

Date: _______________________________