The WHO surgical safety checklist
- Safe practice
The surgical team pauses at three points of an operation to confirm the critical safety items out loud.
What it is
In 2008–2009, as part of the «Safe surgery saves lives» campaign, WHO published a checklist for the operating room. The team makes three pauses: before induction of anaesthesia (sign in), before skin incision (time out) and before the patient leaves the operating room (sign out). At each pause the team confirms out loud, from the checklist and not from memory, the patient's identity, the site and the procedure, anaesthetic risks, prophylaxis and the counts, among other items. WHO encourages each institution to adapt the checklist without removing its essential items. In Colombia, the MinSalud technical guide of good practices recommends it to ensure the right surgery on the right patient and the right site.
What it requires
- The whole team takes part: surgery, anaesthesia and nursing.
- One person coordinates the checklist and can stop progress if an item is not met.
- Verbal confirmation from the checklist, not from memory.
- Surgical site marked when there is laterality or levels, with the patient involved if able.
- Local adaptation is allowed, without removing the essential items.
Components
- Sign in (before induction): the patient confirms identity, site, procedure and consent; the marking, the anaesthesia machine and medicines, a working pulse oximeter, allergies, the risk of difficult airway or aspiration and the risk of major bleeding are reviewed.
- Time out (before incision): everyone introduces themselves; patient, site and procedure are confirmed again; antibiotic prophylaxis within the set time is checked; each discipline anticipates its critical events; sterility and the availability of essential imaging are confirmed.
- Sign out (before leaving the operating room): nursing confirms out loud the procedure performed, the instrument, sponge and needle counts, specimen labelling and any equipment problems; the team reviews the key concerns for recovery.
How it is applied (and why)
- Assign a checklist coordinator before starting: someone must have the responsibility and the authority to stop the process.
- At sign in, ask the patient to confirm who they are, what is being operated on and where: an awake patient is the best source of verification.
- Check the site marking and the signed consent: this prevents surgery on the wrong side or level.
- Confirm with anaesthesia the equipment check, the oximeter, allergies, the airway and bleeding risk: the team can prepare before a problem arises.
- At time out, ask everyone to introduce themselves by name and role: a team that knows each other communicates better in an emergency.
- Together, confirm patient, site and procedure, antibiotic prophylaxis and expected critical events: this is the last barrier before incision.
- At sign out, read aloud the procedure performed and the counts: an incomplete count is resolved before closing or moving the patient.
- Check specimen labels against the patient's details and report equipment faults: this prevents pathology errors and repeat problems.
- Record the checklist per protocol and pass the key points to the recovery team: safety continues after the operating room.
The three phases at a glance
| Phase | When | What is confirmed (summary) |
|---|---|---|
| Sign in | Before induction of anaesthesia | Identity, site, procedure, consent, marking, anaesthesia safety, oximeter, allergies, airway, bleeding risk |
| Time out | Before skin incision | Team introductions, patient-site-procedure, antibiotic prophylaxis, critical events, sterility, imaging |
| Sign out | Before the patient leaves the operating room | Procedure performed, counts, specimen labelling, equipment faults, recovery plan |
In nursing practice
- Nursing takes part in all three phases and usually handles the counts.
- The checklist is also a communication tool: it gives anyone permission to speak up if they see a risk.
- It only works if it is truly used, not just ticked.
- It links with patient identification and with the informed consent checked on the ward and in the pre-operative area.
Common mistakes
- Filling in the checklist after surgery or without the team stopping.
- Doing the time out without the surgeon or anaesthetist present.
- Confirming «from memory» without reading the checklist.
- Accepting an incomplete count so as not to delay closure.
- Removing essential items when adapting the checklist.
Test yourself
Think of the answer, then tap the question to see it.
What are the three phases of the WHO surgical safety checklist and when is each one done?
Sign in, before induction of anaesthesia; time out, before skin incision; and sign out, before the patient leaves the operating room.
What is confirmed during the time out?
That everyone has introduced themselves by name and role; patient, site and procedure; antibiotic prophylaxis; the critical events each discipline expects; and the availability of essential imaging.
What does nursing confirm out loud at sign out?
The name of the procedure performed, that the instrument, sponge and needle counts are complete, specimen labelling and whether there were any equipment problems.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Implementation manual WHO surgical safety checklist 2009: Safe surgery saves lives (World Health Organization (WHO), 2009); Safe surgery: tool and resources (World Health Organization (WHO), 2009); Safe Surgery Saves Lives: Surgical Safety Checklist starter kit (World Health Organization (WHO), 2009); Guía técnica Buenas prácticas para la seguridad del paciente en la atención en salud, versión 1 (Ministerio de la Protección Social (MinSalud), Colombia, 2010).
Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake
Representative model, for educational purposes only.