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Surgical Safety Checklist for Healthcare Teams

Surgical Safety Checklist for Healthcare Teams

Safety Checklists
100 Items
Comprehensive surgical safety checklist covering pre-operative preparation, anesthesia planning, equipment verification, and postoperative care for patient safety.

Comprehensive Surgical Patient Safety Guide

This comprehensive surgical safety checklist provides a systematic approach to ensuring patient safety throughout the entire surgical process. The safety protocol covers pre-operative patient preparation and verification, anesthesia and airway planning, equipment and sterility verification, team briefing and time-out procedures, intraoperative monitoring and safety measures, communication and documentation requirements, closure and sign-out procedures, postoperative handover protocols, surveillance and complication prevention, and quality assurance and continuous improvement. Use this checklist to prevent surgical errors, reduce complications, ensure proper team communication, maintain sterile technique, and implement evidence-based safety practices that protect patients and improve surgical outcomes.

1. Pre-operative / Patient Preparation

1Confirm patient identity (name, date of birth, ID number)
2Confirm surgical procedure, side, and site with consent
3Verify informed consent is signed and in the chart
4Review patient's medical history, allergies, comorbidities
5Ensure required preoperative investigations (labs, imaging) are available
6Confirm patient has adhered to NPO (nil per os / fasting) instructions
7Confirm presence of surgical site marking (if applicable)
8Review anticoagulation, antiplatelet therapy and hold/bridge plan
9Confirm availability of preoperative antibiotics (if required)
10Ensure preoperative physical preparation (skin preparation, hair clipping, bowel prep etc.)

2. Anesthesia / Airway Planning

1Confirm planned anesthesia technique (general, regional, sedation)
2Review airway assessment (Mallampati, neck mobility, predictors of difficulty)
3Confirm aspiration risk / fasting status
4Check functioning of anesthesia machine and circuits
5Verify backup airway equipment (e.g. laryngeal mask, video laryngoscope, difficult airway cart)
6Confirm availability of emergency drugs (e.g. vasopressors, reversal agents)
7Ensure suction is working and tubing is available
8Confirm adequacy of monitoring (ECG, BP cuff, SpO₂, capnography etc.)
9Confirm IV access (size, number, location) and fluid plan
10Confirm patient's hemodynamic baseline and plan for intraoperative monitoring

3. Equipment, Instruments, and Sterility

1Verify all required surgical instruments are available and functioning
2Confirm instrument count sheets / system are ready
3Ensure availability of sterile disposables, drapes, gowns, gloves
4Confirm sterilization indicators confirm sterility of sets
5Ensure availability of cautery/electrosurgical equipment and appropriate settings
6Confirm backup or alternative equipment (e.g. alternate suction, backup light sources)
7Verify availability of hemostatic agents, sutures, staples, clips
8Confirm appropriate surgical implants or prostheses are available
9Confirm functioning of lighting, camera or optics if needed
10Check that all equipment cables / tubes are correctly labeled and untangled

4. Time-Out / Team Briefing (Pre-Incision Pause)

1All team members introduce themselves by name and role
2Confirm patient identity, surgical site, and procedure one more time
3Confirm that antibiotic prophylaxis has been given within acceptable timeframe
4Confirm expected blood loss, need for transfusion, and availability of blood products
5Review critical or non-routine steps of the surgery
6Anticipate possible complications and plan responses
7Confirm sterile field is established and team ready
8Confirm imaging, scans, or navigation tools are displayed and available
9Confirm that all team members are comfortable to speak up if concerns arise
10Confirm that surgical counts (sponges, instruments, needles) start as per protocol

5. Intraoperative Monitoring & Safety

1Continuously monitor vital signs: HR, BP, SpO₂, end-tidal CO₂, temperature
2Monitor urine output (if catheterized) or other perfusion markers
3Monitor blood loss and fluid balance in real time
4Watch for signs of hypoxia, hypercapnia, hypotension, arrhythmia
5Regularly reassess anesthetic depth and analgesia
6Ensure maintenance of sterile technique throughout
7Confirm proper positioning and padding to avoid pressure injuries
8Adjust and check surgical field lighting, camera focus etc.
9Label and manage all tubes, lines, drains correctly
10Pause as needed to recheck counts, instruments, and team communication safety

6. Communication & Documentation

1Document all times (incision, key steps, blood loss, start/stop)
2Document any deviations from the plan and reasons
3Communicate intraoperative events to circulating nurse and anesthesiologist
4Use clear verbal callouts of critical events (e.g. bleed, change of plan)
5Confirm the presence of required documentation in chart (e.g. consent, labs)
6Record medications and dosages administered intraoperatively
7Record any intraoperative complications or adverse events
8Communicate to team when entering critical phases (e.g. vascular, resection)
9Confirm that all specimens are labelled correctly and tracked
10At regular intervals, verbally confirm team is aligned with plan

7. Closure / Sign-Out (Pre-Leaving OR)

1Confirm name of procedure completed
2Perform final instrument, sponge, and needle counts
3Confirm count results verbally and document them
4Confirm specimen labeling (patient name, ID, site)
5Confirm that surgical / hemostatic concerns are resolved
6Confirm all lines, drains, catheters are accounted for and documented
7Confirm equipment problems to be addressed (e.g. malfunctioning devices)
8Verbalize key concerns for recovery (e.g. airway, bleeding, pain)
9Confirm plan for postoperative monitoring and ICU/ward transfer
10Ensure that team members (surgeon, anesthetist, nurse) share outstanding concerns

8. Postoperative / Handover to Recovery / ICU

1Transfer patient on stable vitals per defined criteria
2Hand over to receiving team: patient history, intraoperative events, medications
3Communicate airway and analgesia plan for postoperative period
4Communicate fluid balance, transfusions, blood loss
5Communicate any critical lab values or pending labs
6Communicate drains, lines, catheters, their function and plan
7Ensure monitoring plan (vitals frequency, parameters to watch)
8Confirm orders for postoperative medications, antibiotics, analgesics
9Confirm plan for imaging or further diagnostics, if needed
10Ensure documentation of handover and signature of receiving clinician

9. Postoperative Surveillance & Complication Prevention

1Monitor for signs of bleeding, hematoma, hemodynamic instability
2Monitor for signs of infection: temperature, wound, lab markers
3Monitor respiratory status (SpO₂, breathing effort)
4Assess pain regularly and manage appropriately
5Monitor urine output / renal function
6Assess neurological status if relevant (e.g. after neuro, spinal cases)
7Monitor for thromboembolism risk: prophylaxis orders, mobilization
8Monitor for pressure injuries, skin integrity
9Review medications for interactions or complications
10Conduct early postoperative check of wound, drains, dressings

10. Quality Assurance, Audit & Continuous Improvement

1Document compliance with checklist items for each case
2Review and audit missed or waived items and reasons
3Conduct periodic multidisciplinary debriefing and feedback sessions
4Track surgical outcomes, complications, "near misses"
5Identify patterns or systemic causes of checklist noncompliance
6Update checklist items to reflect local risk or specialty needs
7Train new staff in checklist use and safety culture
8Monitor "stop the line" events or interventions prompted by checklist
9Share audit outcomes with surgical teams and leadership
10Use incident reports to revise protocols, develop preventive strategies
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