WHO SURGICAL SAFETY CHECKLIST

Name: Rodriguez, Jake T. Ward/Room: Male Surgical Isolation

Ward, Bed #1
Address: Brgy. 1, Bacolod City
Age: 16 years old Sex: Male Admission Date: November 3, 2021

SIGN IN
Before Induction of Anesthesia
/ Patient identity confirmed / IV access and antimicrobial prophylaxis
/ Procedure and consent / Operating room equipment
/ Laterality and markings x Allergies and airway risk
/ Anesthesia intervention / Blood availability

TIME OUT
Before Skin Incision
/ Patient identity confirmation
x Procedure, laterality, imaging film displayed (when applicable)
/ Team members induction (surgeon, anesthesiologist, nurses, etc.)
x Any anticipated critical events (co-morbid precautions)

SIGN OUT
Towards Final Closure of Skin
/ Complete name of procedure x Intraoperative antibiotics given (when applicable)
/ Instruments, sponge, needle, etc., count x Number of packing ( when applicable)
is correct and complete
x How specimen should be labeled x Concerns to be addressed

Be polite. Thank everyone.

Dr. Salvador Dr. Mondragon Hermie Siroy, RN, MN

Surgeon Anesthesiologist Circulating Nurse