Blue Safety Checklist

Surgical Safety
1 Sign In
(Before induction of anaesthesia) 2 Time Out
(Before skin incision) 3 Sign Out
(Before patient leaves operating room)

● Patient has confirmed: ● Confirm all team members have introduced Nurse verbally confirms with the team:
• Identity themselves by name and role
• Site ● The name of the procedure recorded
● Surgeon, anaesthesia professional and
• Procedure nurse verbally confirm:
● That instrument, sponge and needle
• Consent counts are correct (or not applicable)
• Patient
● Site marked/not applicable • Site
● How the specimen is labelled
• Procedure
● Anaesthesia safety check completed (including patient name)
Anticipated critical events
● Pulse oximeter on patient and functioning ● Whether there are any
● Surgeon reviews: What are the critical or equipment problems to be
Does patient have a known allergy? unexpected steps, operative duration, addressed
● No anticipated blood loss?
● Anaesthesia team reviews: Are there any ● Surgeon, anaesthesia professional
● Yes and nurse review the key concerns
patient-specific concerns?
for
Difficult airway/aspiration risk? ● Nursing team reviews: Has sterility (including
indicator results) been confirmed? Are there recovery and management of this patient
● No
equipment issues or any concerns?
● Yes, and equipment /assistance available
Has antibiotic prophylaxis been given within
Risk of >500ml blood loss (7ml/kg in children)?
the last 60 minutes?
● No
● Yes
● Yes, and adequate intravenous access
and fluids planned ● Not applicable

Is essential imaging displayed?

● Yes

● Not applicable

Based on the WHO Surgical Safety Checklist, URL http://www.who.int/patientsafety/safesurgery/en, © World Health Organization 2008 All rights reserved. More information can be found
at: http://www.who.int/patientsafety/safesurgery/using_checklist/en/index.html.