WHO surgical safety checklist, time out, sign out and surgical item count protocol

Surgical Control

KEIT DAY HOSPITAL

WHO surgical safety checklist, time out, sign out and surgical item count protocol

Official Manual of Clinical, Care and Organizational Protocols

1. Document Control Information

2. Scope of Application

Applicable to all surgical and invasive procedures performed in the operating room.

3. Responsibilities

• Surgeon, anesthesiologist and operating room nurse: mandatory participation in all phases of the checklist.
• Scrub nurse and operating room nurse: performance and documentation of surgical item counts.

4. Operating Procedure

• Perform the Sign In before anesthesia, confirming the patient’s identity, procedure, consent, surgical site, allergies, bleeding risk and the availability of required examinations and equipment.
• Perform the Time Out immediately before incision, with the active participation of the entire team.
• Administer antibiotic prophylaxis within the appropriate timeframe and verbally confirm that it has been completed.
• Perform initial, intraoperative and final counts of instruments, needles, surgical sponges and other materials in accordance with the established procedure.
• Perform the Sign Out before the patient leaves the operating room, confirming the procedure performed, any identified concerns, specimens, final count and postoperative plan.
• Immediately manage any count discrepancy until it has been resolved and fully documented.

5. KEIT Operational Standards

• The WHO Surgical Safety Checklist is an integral and mandatory component of the KEIT surgical pathway.
• Surgical item counts are performed rigorously and documented in the operative record.

6. Records and Documentation

• Signed surgical checklist.
• Surgical item count form.
• Record of any identified count discrepancies.

7. Review and Updates

Regular audits of compliance with the checklist and surgical item count procedures.

8. Related Attachments and Forms

Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol. Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.

9. Final Approval