COMPREHENSIVE SURGICAL CHECKLIST

Blue = World Health Organization (WHO) Green = The Joint Commission - Universal Protocol 2016 National Patient Safety Goals Teal = Joint Commission and WHO

PREPROCEDURE CHECK-IN SIGN-IN TIME-OUT SIGN-OUT

In Preoperative Ready Area Before Induction of Anesthesia Before Skin Incision Before the Patient Leaves the
Operating Room

Patient or patient representative RN and anesthesia professional Initiated by designated team member: RN confirms:
actively confirms with registered confirm: All other activities to be suspended (except in
nurse (RN): case of life-threatening emergency)

Identity  Yes Confirmation of the following: identity, Introduction of team members  Yes Name of operative procedure:
Procedure and procedure site  Yes procedure, procedure site, and All:
Consent(s)  Yes consent(s)  Yes Confirmation of the following: identity, Completion of sponge, sharp, and
Site marked  Yes  N/A Site marked  Yes  N/A procedure, incision site, consent(s)  Yes instrument counts  Yes  N/A
by the person performing the procedure by person performing the procedure Site is marked and visible  Yes  N/A Specimens identified and labeled
Patient allergies  Yes  N/A Fire Risk Assessment and Discussion  Yes  N/A
RN confirms presence of:
Pulse oximeter on patient  Yes  Yes (prevention methods implemented) Equipment problems to be addressed
History and physical  Yes
Difficult airway or aspiration risk  N/A  Yes  N/A
Preanesthesia assessment  Yes
 No  Yes (preparation confirmed) Relevant images properly labeled and Discussion of Wound Classification
Nursing assessment  Yes
Risk of blood loss (> 500 mL) displayed  Yes  N/A  Yes
Diagnostic and radiologic test results
 Yes  N/A Any equipment concerns  Yes  N/A To all team members:
 Yes  N/A
# of units available Anticipated Critical Events What are the key concerns for
Blood products  Yes  N/A
Anesthesia safety check completed Surgeon: States the following: recovery and management of this
Any special equipment, devices, patient?
 Yes  Critical or nonroutine steps
implants  Yes  N/A
Briefing:  Case duration
All members of the team have  Anticipated blood loss
discussed care plan and addressed Anesthesia professional:
Include in Preprocedure check-in
as per institutional custom: concerns  Yes Antibiotic prophylaxis within 1 hour before
Beta blocker medication given incision  Yes  N/A Debriefing with all team members:
 Yes  N/A Additional concerns  Yes  N/A Opportunity for discussion of
Venous thromboembolism Scrub person and RN circulator:  team performance
prophylaxis ordered Sterilization indicators confirmed  Yes  key events
 Yes  N/A
Additional concerns  Yes  N/A  any permanent changes in
Normothermia measures
 Yes  N/A RN: the preference card
Documented completion of time out  Yes June 2016

The Joint Commission does not stipulate which team member initiates any section of the che cklist except for site marking. The Joint Commission
also does not stipulate where these activities occur. See the Universal Protocol for details on the Joint Commission requirements.