Implementation Guide
Surgical Safety Checklist
April 2010
Operating Room Nurses Association of Canada
Canadian Anesthesiologists’ Society
Royal College of Physicians and Surgeons of Canada
Adapted from
Canadian Patient Safety Institute Implementation Kit for the Surgical Safety Checklist
and
WHO Surgical Safety Checklist condensed How-to-Guide
Approved by the WRHA Surgery Program
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Introduction:
Existing data shows that 4%-16% of hospitalized patients suffer harm and surgery is
involved in half of these cases. Significant improvements in the safety of anesthesia over
the past three decades have contributed to the overall safety of surgery; however concern
remains about the frequency of surgically-related complications. Several factors are
recognized as contributing to these complications including:
 increase in the population;
 increase demand for surgery;
 shortage and diversity of healthcare human resources; and
 the continuously changing technologies/ standards that add complexity to already
intricate procedures.
Note: These factors cannot be considered excuses for less than optimal surgical
safety.
The Surgical Safety Checklist is:
 a tool to promote patient safety in the perioperative period;
 intended to give teams a simple, efficient set of priority checks for improving
effective teamwork and communication; and
 intended to encourage active consideration of the safety of patients in every
operation performed.
The Checklist has two (2) purposes:
1. Ensure consistency in patient safety; and
2. Introduce and maintain a culture that values achieving it.
The “OR Team” is understood to include:
 surgeons;
 anesthesiologists;
 nurses;
 technicians; and
 other OR personnel.
Although many of the steps in the checklist are already followed, rarely are all the tasks
and items checked all the time by all OR teams in all facilities, because of many factors,
such as time pressure, shift changes, and the presence of more than one surgical team (as
in multiple trauma cases) .
The World Health Organization (WHO) lists ten (10) objectives that safe surgery should
achieve (objectives are fully accepted by the Canadian Working Group).
1. The team will operate on the correct patient at the correct site.
2. The team will use methods known to avoid harm from the administration of
anesthesia, while protecting the patient from pain.
3. The team will recognize and effectively prepare for life-threatening loss of the
patient’s airway or respiratory function.
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4. The team will recognize and effectively prepare for the possibility of high blood
loss.
5. The team will avoid inducing any allergic or adverse drug reaction known to be a
significant risk for the patient.
6. The team will consistently use methods known to minimize the possibility of
surgical site infection.
7. The team will work to avoid the inadvertent retention of instruments or sponges in
surgical wounds.
8. The team will secure and accurately identify all surgical specimens.
9. The team will effectively communicate and exchange critical patient information
for the safe conduct of the operation.
10. Hospitals and public health systems will establish routine surveillance of surgical
capacity, volume, and results.
The Checklist promotes patient safety through two mechanisms:
1. Provides a list of tasks to be completed and items to be considered in the
perioperative period. By going through the Checklist, the OR team members gain
visual and/or verbal confirmation that these tasks and items have been
implemented and/or addressed at various points in the perioperative period. The
use of the Checklist can help to reduce the frequency of tasks and items
overlooked, put off, or otherwise forgotten.
2. The process of ensuring that each of the tasks and items has been addressed will
require members of the OR team to engage in discussion about the Checklist.
Discussion should also help team members understand each other’s specific roles
and capabilities, foster reflection, increase communication, and strengthen the OR
team.
The Canadian Patient Safety Institute (CPSI), in collaboration with the University Health
Network in Toronto, has partnered with the following organizations to adapt and
implement the Safe Surgery Checklist to the Canadian context:
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Accreditation Canada
Canadian Anesthesiologist’s Society
Canadian Association of Pediatric Health Centres
Canadian Medical Association
Canadian Nurses Association
GreenDot Global
Nova Scotia Department of Health
Operating Room Nurses Association of Canada
Ottawa Heart Institute
Patients for Patient Safety Canada
Regina Qu’Appelle Health Region
Royal College of Physicians and Surgeons of Canada
Society of Obstetricians and Gynecologists
Suresurgery
University of Calgary
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Successful implementation requires adapting the Checklist to local routines and
expectations. Commitment is required from hospital leaders. To be successful, chiefs of
surgery, anesthesia and nursing departments must publicly embrace the belief that safety
is a priority and that use of the Checklist can help make it a reality.
Completion of the Checklist:
The Checklist is a verbal tool developed to support excellent patient care through good
preparation and teamwork. The checklist is not intended to be part of the patient
health record. The value of the Checklist is not reflected in the completion of a form and
it is important to avoid the phenomenon of “tick and flick”, a process of automatically
filling out a form without attention to the content or intent of the item.
The responsibility for implementing and ensuring adherence to all components of the
Checklist rests with one or more representatives of the three groups of professionals who
make up traditional OR teams: surgeons, anesthesiology, and nursing. The responsibility
to carry out the checklist lies with ALL members of the surgical team. If reminders are
required, every member of the team must feel comfortable in initiating the process.
Completion of the Checklist takes approximately three (3) to four (4) minutes.
Patient Awareness Education:
The nurse in the preoperative area shall review the purpose of the Surgical Safety
Checklist with the patient during the preoperative assessment. Information reviewed with
the patient should not be new information as all of the elements of the surgical checklist
should have been provided to the patient during the Informed Consent process.
Components of the Surgical Safety Checklist:
The Surgical Safety Checklist is divided into three (3) components:
 Briefing;
 Time-out; and
 Debriefing.
Item(s) on the Checklist (i.e anticipated blood loss) that are not applicable to the
procedure being performed are not required to be completed. The Lead may be any
member of the surgical team (surgeon, anesthesiologist, or nurse). The Lead is
responsible to confirm with the applicable team member that each item has been
addressed. A Lead has been designated for each component as indicated on the Surgical
Safety Checklist.
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BRIEFING:
Briefing occurs before induction of anesthesia. At a minimum, briefing requires the
presence of the anesthesiologist and nursing personnel. The Lead for the briefing is the
circulating nurse or anesthesiologist.
It is essential that the patient is awake and actively participates in the Briefing
component. Patient refusal to participate is required to be documented in the patient
health record.
Patient Verification
 Verbal confirmation with the patient:
o their identity using two patient identifiers;
o consent for surgery.
 For elective procedures, if confirmation by the patient is not
possible (i.e. children, incapacitated patient), then nursing will
confirm that verbal confirmation of consent was obtained from a
guardian or family member.
 In an emergency procedure “when the patient or substitute decision
maker is unable to consent and there is demonstrable severe
suffering or an imminent threat to the life or health of the patient, a
doctor has the duty to do what is immediately necessary without
consent. Emergency treatments should be limited to those
necessary to prevent prolonged suffering or to deal with imminent
threats to life, limb or health. Even when he/she is unable to
communicate, the known wishes of the patient must be respected.
A careful and complete note should be made of this step in the
patient’s health record.
o the type of procedure planned; and
o the site (side and/or level of surgery);
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Site marked/Not applicable:
o Confirm that the surgeon performing the surgery has marked the surgical
site according to WHRA Policy “Correct Site, Correct Procedure and
Correct Patient for Surgical Procedures (Identification of) #110.220.020”.
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Allergies/Precautions:
o Does the patient have any known allergies?
o If so, what are the specific allergies? Are latex allergy precautions
required? This question is asked to confirm that the anesthesiologist and/or
surgeon are aware of any allergies that the patient might have. If the Lead
knows of an allergy of which the anesthesiologist/surgeon is not aware,
then this information shall be communicated and discussed.
o Is the patient on any specific infection control precautions? If so what?
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VTE prophylaxis
o Is the patient receiving/to receive chemical (anti-coagulant) VTE
prophylaxis?
 Confirm if patient has been taking any type of anticoagulant;
 Confirm if patient has stopped and reused anticoagulants; and
 Confirm if heparin has been substituted and then stopped.
o Is the patient receiving/to receive mechanical (TEDs or SCDs) VTE
prophylaxis?
o Confirm TEDs/SCDs have or will be applied as per surgeon request &/or
hospital policy.
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Equipment, Instrument(s) and/or Implant(s) Concerns?
o Equipment:
 This allows a chance to confirm availability of special equipment,
required or as previously requested by surgeon.
 Confirmation of the intended position is required. The circulating
nurse will confirm that appropriate support and positioning devices
are either in place or are available.
 This is an opportunity for OR team members, including, where
appropriate, surgical equipment manufacturing representatives, to
highlight the need to discuss any problems with equipment and
other preparations for surgery or any safety concerns the scrub or
circulating nurse(s) may have.
o Instrument(s):
 This allows a chance to confirm availability of instrument(s)
required or as previously requested by the surgeon.
 Nurse verifies the sterility indicator/integrator in each
package/tray. Verbally confirm that sterilization of instruments has
been verified. Any discrepancy between the expected and actual
sterility indicator/integrator results of the instruments should be
reported to all team members and addressed before incision.
 If there are no particular concerns, then the scrub nurse can simply
say, “Sterility was verified. I have no special concerns.”
o Implant(s)
 This allows a chance to confirm availability of implant(s) required
as previously requested by the surgeon.
 Availability of various sizes of implants that could be used shall be
confirmed.
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Anesthesia safety check
o Has the anesthesia safety checklist been completed in accordance with
local/departmental policies, such as the Pre-Anesthetic Checklist.
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Difficult Airway/Anesthesia Risk?
o Confirm with anesthesia that required airway equipment is available.
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o Anesthesia shall confirm that they have evaluated the degree of difficulty
of the patient’s airway and the likelihood of pulmonary aspiration of
gastric contents.
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Risk of > 500ml of blood loss?
o May include information related to coagulation test results (PT/PTT/INR)
o Anesthesia/Surgeon should describe any patient characteristics,
medications, or morbidities (i.e. cardiac or pulmonary disease, blood
disorders, etc) that may lead to complications and state his or her intention
to transfuse blood products.
o Confirm blood products are required and available.
 If surgery may result in significant blood loss (greater than 500 ml
in an adult patient), then it is highly recommended that the patient
have at least two large bore intravenous lines or a central venous
catheter inserted before the skin incision is made.
 The OR team shall confirm the availability of fluids or blood for
resuscitation.
o Confirm availability of blood and blood products as
required.
o If use of a cell saver is being considered, then steps
should be taken to ensure that the appropriate
equipment and personnel are available and prepared.
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Postoperative destination
o Is the patient’s post operative destination expected to change based on
information communicated in briefing?
o If so, is a bed available in the intended new destination?
o What factors may make the duration of the procedure unpredictable
resulting in potential for change to postoperative destination?
*At this point the Briefing is completed and the team may proceed with induction of
anesthesia, followed by positioning, prepping and draping.*
TIME-OUT:
At a minimum, surgeon(s), anesthesiologist(s), and nurse(s) must be present for the
Time-Out. Time-out is performed after induction, prepping, and draping immediately
prior to the surgical incision as per WRHA Correct Site, Correct Procedure and Correct
Patient for Surgical Procedures (Identification of) policy #110.220.020. Note: Some
procedures have received approval for alterations to the timing of the Time-Out i.e.
ophthalmic procedures. The Lead for Time Out is the Surgeon. The order of discussion
does not matter. During routine procedures or those with which the entire team is
familiar, the surgeon may simply state, “This is a routine case of ‘X’ duration.
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Team members are identified
o Each team member is identified by Name and Role. If team members
have previously introduced themselves, it is not required to repeat this
step.
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Team verbally confirms
o Correct Patient;
o Correct Procedure; and
o Correct Site.
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Antibiotic prophylaxis given within the appropriate time frame.
o Confirm that Antibiotic Prophylaxis has been given within the last 60
minutes (exceptions Vancomycin and Fluroquinolones within 2 hours) and
when next dose will be given.
o If a prophylactic antibiotic has not been administered, administration is
required before the incision is made.
o If prophylactic antibiotic was administered more than 60 minutes
(exceptions Vancomycin and Fluroquinolones within 2 hours) before the
incision is to be made, the team should consider giving the patient a
second dose of antibiotic.
o Calculation of the time should also include consideration of antibiotic
circulation time and duration of tourniquet time.
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Essential imaging displayed?
o Has essential imaging been displayed and displayed correctly.
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Team communicates anticipated complications
o It is understood that many surgeries do not entail such particularly critical
concerns or potential complications that must be shared with the team. In
these cases, the anesthesiologist/surgeon can simply say “I have no special
concerns about this patient and his/her procedure.”
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STOP! Does everyone agree we are ready to go?
o This question affords the opportunity for one last check with the entire OR
team to ensure that there are no outstanding issues/concerns before
procedure moves forward and incision is made. In the event that this
“Go/No” question leads to further discussion, the issues/concerns shall be
resolved appropriately to the satisfaction of the OR team member who
brought up the issue for discussion.
*At this point the Time-Out is completed and the team may proceed with the
surgery.*
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DEBRIEFING:
Debriefing is the period during or immediately after wound closure PRIOR to the patient
being transferred from the operating room. Debriefing should be accomplished before
the surgeon and patient leave the room. At a minimum, surgeon(s), anesthesiologist(s),
and nurse(s) must be present for the debriefing. The Lead for the Debriefing is the
Circulating Nurse. Debriefing should be initiated when informing the surgeon that
“Count is Correct”.
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Nurse verbally confirms with the entire team
o Confirmation of procedure performed as stated by surgeon.
o Verbal confirmation of specimen including specimen type, labeling and
required examination by reading aloud the patient’s name, description of
the specimen, type of examination requested, and any orienting marks on
the specimen.
o Verbal confirmation that instrument/sponge/needle counts are correct as
per WRHA Surgical Count – Operating Room Policy #110.220.010.
o Identification of equipment problems (if applicable):
 any problems with equipment (machines, positioning devices, etc)
that may have arisen during the procedure and the plan in place to
address any malfunction; and
 any concerns with skin integrity.
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Surgeon reviews with the entire team
o A summary of important intra-operative events, such as unexpected
findings or changes to the operating plan.
o Indicate management plans.
o In many cases the surgeon may simply state that “routine” surgery
was performed.
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Anesthesiologist reviews with the entire team
o Summary of important events that may have occurred related to the
anesthetic including, but not limited to any concerns related to fluid
balance/management.
o May confirm blood/fluid loss.
o Recovery plans including any concerns/issues related to postoperative
ventilation, pain management, glucose control, and temperature
correction/maintenance. What are the KEY concerns for this patient’s
recovery and management? There should be agreement with the surgeon
on recovery plans, which will be started in the Post Anesthesia Care Unit
(PACU) and then carried on when the patient is transferred to the patient
care unit/Intensive Care Unit (ICU).
o Confirm whether normothermia was maintained.
o In many cases the anesthesiologist may simply state that a “routine”
anesthetic was provided.
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Is there anything we could have done better?
o Must be asked for each procedure.
o All team members must respond with either a negative or a specific
answer to the question. Any specific answers should be collected and
presented to the appropriate individual(s) so that other team(s) can learn
from what occurred or could have occurred.
o Consider three (3) questions when answering:
 What did we do well?
 What did we learn?
 What could we do better/do differently?
*Hand-off to PACU/RR, patient care unit or ICU*
SAFETY CHECKLIST IS NOW COMPELTE
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Reference List
Canadian Patient Safety Institute Implementation Kit for the Surgical Safety Checklist,
2009.
WHO Surgical Safety Checklist condensed How-to-Guide, 2008.
WRHA Policy 90.00.050 “Sterilizer Quality Assurance Monitoring”
WRHA Policy #110.000.005 “Informed Consent (for Procedures, Treatments and
Investigations)”
WRHA Policy #110.220.010 “Surgical Count – Operating Room”
WRHA Policy #110.220.020 “Correct Site, Correct Procedure and Correct Patient for
Surgical Procedures (Identification of)”
WRHA Policy #110.220.070 “Pathology Specimens – Acute Care Setting (Management
of)”
WRHA Surgery Program Preop History and Physical Form
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