Edited Modified WHO Surgical Safety Checklist For Surgical Patients During The COVID19 Pandemic

NSGOR-FM-016/Rev.
1/31Jan2022
Republic of the Philippines
Department of Health
Mayor Hilarion A. Ramiro Sr. Medical Center
Maningcol, Ozamiz City
Modified WHO Surgical Safety Checklist for Surgical Patients during the COVID19 Pandemic
Name:______________________________________________ Age: ________ Sex: _________ Date: __________________ Hospital #: _________________________
Pre-Operative Diagnosis: ____________________________________________ Planned Operation: ___________________________________________________
Checklist Parameter Question for Documentation Response

I. SIGN IN: Upon arrival of the patient in the OR theater, before YES NO N/A
induction (with at least nurse and anesthesiologist)
Verified patient identity Correct patient?
Verified COVID status Does patient have COVID19 based on
If other test used, indicate RTPCR test?
test/date Date RTPCR done:
_____________
*If RT-PCR is (-)ve but still mm/dd/yyyy
considering COVID19 Rapid Antigen test / Date: ___________
Verified COVID vaccination Did patient receive complete dose of
status vaccination vs COVID?
Provided a new surgical mask to Does the patient have a new surgical
the patient if not intubated mask on?
Verified planned procedure Correct procedure?
Marked site/side/level Correct site/side/level marked?
Checked signed consent Consent signed?
Confirmed imaging data Confirmed imaging data displayed?
Checked for allergies Does patient have a known allergy?
Checked for airway or Does the patient have a known
aspiration risks airway/aspiration risk?
Checked if correct implants and Correct implants and prosthesis
prosthesis, equipment available? available?
Checked if AGP precautions in Are AGP precautions in place?
place
Checked IV access Are there two lines present for cases with
EBL > 500 ml in adults?
(>7 ml/kg in pediatric patients)
Surgical machines thoroughly Surgical machines covered in new cling
wiped down and functional wrap and functioning?
Checked if PPEs of OR staff are Are the PPEs of the operating team
appropriate and intact appropriate and intact?
Checked if team members are Are the team members inside the OR at
away from patient during the far end of the room prior to
intubation/other AGPs intubation?
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NSGOR-FM-016/Rev.1/31Jan2022

II. TIME OUT: Before Skin Incision (with nurse, anesthesiologist and YES NO N/A
surgeon)
Verified patient name, planned Correct patient?
procedure & incision site Correct procedure?
Correct site/side/level?
Operating team introduced All team members have introduced

themselves by name and role themselves and their roles?
Check if all members of the Are the PPEs of the operating team
operating team have appropriate appropriate and intact?
and intact PPEs Surgeon?
First Assist?
Second Assist?
Anesthesiologist?
Anesthesia Assist?
Anesthesia Care Nurse?
Circulating Nurse?
Scrub Nurse?
Check if antibiotic given Has antibiotic prophylaxis been given

within 60 minutes within 60 minutes?
Checked anticipated To Surgeon:
critical events What are the critical, non-routine
steps?
Expected duration of surgery?
Anticipated blood loss (ml)?
To Anesthesiologist:
Any patient-specific concerns?
To Nursing Team:
Has sterility been confirmed?
Are there any equipment issues or

any concerns?
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Name:______________________________________________Age:________ Sex: _________ Date:__________________ Hospital #: _________________________

Post-Operative Diagnosis: ____________________________________________ Operative Procedure: ________________________________________________
YES NO N/A
III. SIGN OUT: Before patient leaves operating room (with nurse, YES NO N/A
anesthesiologist and surgeon) Surgeon?
Verbally confirmed, instrument, Were the instruments, sponge and
sponge, needle counts complete, Anesthesiologist?
needle counts correctly accounted
Checked if all members
aseptic technique of the
observed operatingfor?
and Are the PPEs of the operating team
team have intact
maintained PPEs
throughout intact?
Was aseptic technique observed
Surgeon?
and maintained throughout the
procedure?First Assist?
Surgeon/staff must be out before Have the Second
surgicalAssist?
staff left the
extubation (minimal number of Anesthesiologist?
theater prior to extubation?
surgical staff left inside) Anesthesia assist?
Surgeon/Assist?
Anesthesia
Circulating Nurse? Care Nurse
Circulating Nurse?
Scrub Nurse?
If no, areScrub Nurse?
the staff inside the OR
If not possible to leave the room,
theater at the far end of the room
maintained
Provision of maximum distance
a new surgical maskofto the Does the patient have a new
prior to extubation?
surgeons
patient andintubated
if not nurses from the surgical mask on for the transport?
Surgeon/Assist?
patient during intubation
Checked if transport team in appropriateCirculating
and AreNurse?the transport team members in
intact PPEs appropriate
Scrub Nurse? and intact PPE?
OR Team: Signature:
Surgeon __________________________________ ____________________________________
Verbally confirmed surgical Complete name of the procedures First Assist __________________________________ ____________________________________
procedure done performed verified and
documented?
Second Assist __________________________________ ____________________________________
Specimen identified and labelled Has the specimen been labelled
properly and secured in designated properly, histopathology form Anesthesiologist __________________________________
____________________________________
container filled up and designated specimen
container used? Anesthesia Assist _________________________________
____________________________________
Checked for any equipment Are there any equipment problems
malfunction & issues that need to that need to be addressed Anesthesia Care Nurse ______________________________
____________________________________
be addressed prior to the next case
Circulating Nurse __________________________________
Verified post op care Any key concerns for
____________________________________
endorsements postoperative recovery and
Scrub Nurse __________________________________
management for the patient?
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Edited Modified WHO Surgical Safety Checklist For Surgical Patients During The COVID19 Pandemic

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NSGOR-FM-016/Rev.

Checklist Parameter Question for Documentation Response

Checklist Parameter Question for Documentation Response

Operating team introduced All team members have introduced

Check if antibiotic given Has antibiotic prophylaxis been given

Expected duration of surgery?

Anticipated blood loss (ml)?

Any patient-specific concerns?

Are there any equipment issues or

Name:__________________________________________Age: Sex: _ Date: Hospital #: ___________

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