WHO launched its Surgical Safety Checklist in 2008 as part of the “Safe Surgery Saves Lives” campaign. In a landmark study across eight hospitals in high-, middle- and low-income countries, published in the New England Journal of Medicine in 2009, using the checklist was associated with a fall in deaths from 1.5% to 0.8% and in major complications from 11% to 7%. It is now used in thousands of operating theatres worldwide. Theatre nurses often lead it.
Stage 1: Sign In (before induction of anaesthesia)
With at least the nurse and anaesthetist, confirm:
- The patient’s identity, site, procedure and consent.
- The site is marked (or marking is not applicable).
- The anaesthesia safety check is complete (machine and medication).
- The pulse oximeter is on the patient and working.
- Does the patient have a known allergy?
- Is there a difficult airway or aspiration risk? If so, equipment and assistance are available.
- Is there a risk of blood loss over 500 mL (7 mL/kg in children)? If so, IV access and fluids are planned, and blood is available.
Stage 2: Time Out (before skin incision)
With the whole team: nurse, anaesthetist and surgeon.
- All team members introduce themselves by name and role.
- Confirm the patient’s name, procedure and where the incision will be made.
- Has antibiotic prophylaxis been given within the last 60 minutes?
- Anticipated critical events: the surgeon reviews critical steps, duration and expected blood loss; the anaesthetist reviews patient-specific concerns; the nursing team confirms sterility (including indicator results) and any equipment issues.
- Is essential imaging displayed?
Stage 3: Sign Out (before the patient leaves theatre)
The nurse verbally confirms with the team:
- The name of the procedure recorded.
- That instrument, swab (sponge) and needle counts are correct.
- How the specimen is labelled, including the patient’s name.
- Whether there are any equipment problems to be addressed.
- The surgeon, anaesthetist and nurse review the key concerns for recovery and management of the patient.
Counts: preventing retained items
- Count swabs, needles, blades and instruments before the procedure, before closure of a cavity, and at skin closure, aloud with a second person.
- Record counts on the board and in the record.
- Use only X-ray detectable swabs in the surgical field.
- If a count is incorrect, inform the surgeon immediately; search; X-ray if needed; document.
Making it work, not just ticking boxes
The checklist only works when it is done properly, with the whole team pausing and paying attention. Common problems include completing it silently on paper, rushing, or skipping it in emergencies. Hierarchy can make junior staff reluctant to speak up. WHO encourages adapting the checklist locally, but key items should not be removed.
Every team member, including the most junior nurse, has the right and the duty to stop the procedure if a safety concern hasn’t been resolved. Say it clearly: “I need us to stop. The count is incorrect.”
Wrong-site surgery and other never events
Wrong-site, wrong-patient and wrong-procedure surgery, and retained foreign objects, are classed as “never events” in the NHS because they are preventable with existing safety measures. The checklist is one of the strongest of those measures.
Related: Post-operative nursing care · SBAR · Medication safety
Based on the WHO Surgical Safety Checklist (2009) and implementation manual, and Haynes et al., NEJM 2009. Educational content: follow your local theatre policy.