Surgical safety checklist

WHO Surgical Safety Checklist is very important aspect of safety in the operating rooms of all hospitals.

1. Dr. Shailendra.V.L.
Director Patient Safety
Bukairyah General Hospital

2. Sample Events
The Anesthesia Care Provider inserted the needle to perform
an anesthesia block. The patient felt a twitch in her leg and
stated that the twitch was on the left side and the surgery
should be on the right side. The patient was correct.
No site marking or Time Out had been performed prior to the block.
Site mark for right stent placement placed on arm and was
not visible after prepping and draping. Left stent placement
performed.
Site mark was not visualized during the Time Out.

3. Sample Events
Surgeon consulted on patients in two different rooms.
Surgeon performed knee aspiration on incorrect side thinking
it was the other patient.
Patient identity was not verified and Time Out was not performed.
Patient consented to left knee arthroscopy. Right leg placed in
holder and tourniquet placed. Surgical site had been marked
but when initials were not seen on the right leg surgeon
thought mark was removed by surgical prep.
Site marked was not visualized during the Time Out.

4. At-risk Behaviour in the OR
Not checking equipment before use
Surgeon entering after prep and drape
Surgeon running 2 rooms
Multi-tasking from O.R.
Relying on memory about the pathology
Unannounced substitutions in mid case
Continuing to close during sponge search

5. Impact of Wrong Site Cases
Patient harm, sometimes loss of limb or life
Physical injury and possibly assault
Loss of faith in the healthcare providers
Surgeon litigation and licensure penalties
Hospital litigation and accreditation penalties
Indefensible public image risk
Undermines surgery team cohesion
5

6. Objectives of Safe Surgery
The team will operate on the correct patient at the correct
site
The team will use methods known to avoid harm from the
administration of anesthesia, while protecting the patient
from pain
The team will recognize and effectively prepare for life
threatening loss of the patient’s airway or respiratory
function
The team will recognize and effectively prepare for the
possibility of high blood loss
The team will avoid inducing any allergic or adverse drug
reaction known to be a significant risk for the patient

7. Objectives of Safe Surgery
The team will consistently use methods known to minimize
the possibility of surgical site infection
The team will work to avoid the inadvertent retention of
instruments or sponges in surgical wounds
The team will secure and accurately identify all surgical
specimens
The team will effectively communicate and exchange
critical patient information for the safe conduct of the
operation

8. How to avoid such mishaps
High Reliability Organisations - CARE
Commitment by the Leaders
Attention to the Task
Respond as a Team
Effective Communication

9. O.R. Team Should Be Patient-
focused
Not surgeon-focused
Not workflow-focused
Not specialty-focused
Not budget-focused
Not break-focused

10. Surgical safety checklist
Sign in
Time out
Sign out

11. Strengths of the Surgical
Safety Checklist
Deployable in an incremental fashion
Supported by scientific evidence and expert consensus
Evaluated in diverse settings around the world
Ensures adherence to established safety practices
Minimal resources required to implement a far-
reaching safety intervention

12. Guiding Principles
Simple
Widely applicable
Measurable
Address serious and avoidable surgical
complications
Zero harm from the Checklist

14. What issues does this checklist
address?
◦All important safety elements are reviewed by ALL OR
teams, for ALL patients, at ALL times
◦Promote teamwork and communication
Communication is a root cause of nearly 70% of the events reported to the
Joint Commission from 1995-2005.
◦Preparedness for the unexpected
◦Promotes an environment that allows anyone on the
team to speak up if patient safety is at risk
◦Correct patient, operation and operative site
◦Safe Anesthesia and Resuscitation
◦Minimize the risk of infection

15. (17) Surgical Safety Checklist; Sign In
No. Activity FMPMNMNA
1
Sign In instructions is done before induction of anesthesia
2
The patient confirmed his/her identity, site, procedure and consent
3
The surgical site has been marked  
4
Known allergy is verified
5
Difficult airway/aspiration risk is verified
6
If difficult airway/aspiration risk exist, equipment/ assistance is available
7
If there is risk of >500ml blood loss (7ml/kg in children), adequate IV
access/fluids is planned

8
Antibiotic prophylaxis, if indicated, has been given within the last 60
minutes

9
Confirm that VTE prophylaxes, if indicated, has taken place.  

16. (18) Verification Process/Time Out
No. Activity FMPMNMNA
1
Time- Out is done before skin incision and before starting anesthesia, and
is read out loud
    
2
Time- Out is done with nurse, anesthetist and surgeon or his/ her designee     
3
The surgeon or his/ her designee, anesthetist and nurse verbally confirm the
patient’s name.
    
4
The surgeon, anesthetist and nurse verbally confirm the procedure.     
5
The surgeon provides information regarding the critical or non-routine
steps, if any.
    
6
The surgeon provides information regarding how long will the case take.     
7
The surgeon provides information regarding how much blood loss is
anticipated
    
8
The anesthetist provides information regarding any patient-specific
concerns.
    
9
The nurse has confirmed the sterility of the instrumentation (including
indicator results).
    
10 The nurse has confirmed whether there are equipment issues or concerns.
    
11 The team ensures essential radiology imaging are displayed.     

17. (19) Surgical Safety Checklist; Sign Out
No. Activity FMPMNMNA
1
Sign out instructions is done before patient leaves operating room and is
read loud.
    
2
Sign out is done with nurse, anesthetist and surgeon or his/ her designee.    
3
Nurse verbally confirms the name of the procedure.    
4
Nurse verbally confirms completion of instrument, sponge and needle counts      
5
Nurse verbally confirms specimen preservation (dry, formalin, saline or
water)
     
6
Nurse verbally confirms labeling of the specimen with 2 patient identifiers.      
7
Nurse verbally confirms whether there are any equipment problems to be
addressed
     
8
Surgeon, Anesthetist and Nurse confirm the key concerns for recovery and
management of this patient.
 
   

18. Factors contributing to
failures
“Captain of the Ship” mentality
Surgery team hierarchy
Culture of blame and punishment
Compelling incentives for speed
Little attention to near misses
Failure to adopt “best practices”
Litigation and confidentiality

19. Success stories
An elderly patient undergoing repair of a hip fracture was
prepped for a right-sided procedure, consistent with the
consent, history and physical, and a consultation report.
During the time out, the surgical team determined that
the patient had a left hip fracture, which was then
confirmed by x-ray. The procedure was performed on the
correct side.
Wrong knee was marked in pre-procedure area.
Verification of the site marking against source documents
uncovered the discrepancy and correct site was marked
and surgery completed.

21. Take-Home Points
A Time Out must be completed prior to any invasive
procedure across the organization for every patient, every
time
All Time Outs must be completed following the 5 key
steps in the Time Out process
If there are any discrepancies during the Time Out or a
step is not completed, members of the team will “Stop
the Line” until resolution and agreement by the team
Staff and physicians will be supported by administration in
“Stopping the Line.”

22. Conclusion
Wrong site and wrong patient surgery remains a
problem
Eliminating wrong site and wrong patient surgery will
require widespread utilization of principles of error
management, accepting safety as a core value
Healthcare leaders need to embrace a commitment
to studying our mistakes, developing best practices
and sharing solutions nationwide