Surgical Safety Checklist

Before induction of anaesthesia Before skin incision Before patient leaves operating room
(with at least nurse and anaesthetist) (with nurse, anaesthetist and surgeon) (with nurse, anaesthetist and surgeon)

Has the patient confirmed his/her Confirm all team members have introduced Nurse Verbally Confirms:
identity, site, procedure, and consent? themselves by name and role.
The name of the procedure
Yes Confirm the patient’s name, procedure, Completion of instrument, sponge and
Is the site marked? and where the incision will be made. needle counts
Has antibiotic prophylaxis been given Specimen labelling (read specimen
Yes
within the last 60 minutes? labels aloud, including patient name)
Not applicable Whether there are any equipment
Yes
Is the anaesthesia machine and problems to be addressed
Not applicable
medication check complete? To Surgeon, Anaesthetist and Nurse:
Yes Anticipated Critical Events What are the key concerns for recovery
Is the pulse oximeter on the patient To Surgeon: and management of this patient?
and functioning? What are the critical or non-routine steps?
Yes How long will the case take?
Does the patient have a: What is the anticipated blood loss?
Known allergy? To Anaesthetist:
No Are there any patient-specific concerns?
Yes To Nursing Team:
Difficult airway or aspiration risk? Has sterility (including indicator
No results) been confirmed?
Are there equipment issues or any concerns?
Yes, and equipment/assistance available
Risk of >500ml blood loss (7ml/kg in children)? Is essential imaging displayed?
Yes
No
Yes, and two IVs/central access Not applicable
and fluids planned

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. Revised 1 /
2009 © WHO, 2009
 Surgical Safety Checklist – Sign In, Time Out dan Sign Out Patient Safety Halaman 2/2
Dilakukan sebelum induksi anestesi, dihadiri minimal oleh perawat & ahli Dilakukan sebelum insisi, dihadiri minimal oleh perawat, ahli anestesi, Dilakukan sebelum pasien meninggalkan kamar operasi, dihadiri oleh perawat, ahli anestesi,
anestesi operator operator

Indikator Sudah Belum Indikator Ya Tidak Indikator Ya Tidak

1. Pasien telah dikonfirmasi meliputi : 1. Sebutkan nama dan peran masing-masing seluruh
1. Konfirmasi secara verbal tentang nama prosedur / tindakan :
anggota tim

1) Identitas dan gelang pasien 2. Konfirmasi meliputi : 2. Jumlah instrument, sponge, jarum sesuai ?

2) Lokasi operasi 1) Nama pasien Item Pra Intra + Pasca

3) Prosedur 2) Prosedur Instrument

4) Persetujuan operasi 3) Lokasi insisi Sponge

2. Lokasi operasi sudah diberi tanda 3. Profilaksis Antibiotik Jarum

1) Sudahkah diberikan 60 menit sebelumnya?
Jumlah total
2) Diberikan oleh............................

3. Spesimen telah diberi label (minimal nama, alamat, no RM

3. Mesin dan obat-obat anestesi sudah di cek lengkap 4. Pencegahan Kejadian Tidak Diharapkan (KTD)
dan asal jaringan spesimen)

4. Pulse oximeter sudah terpasang dan berfungsi Bidang Bedah 4. Adakah masalah dengan peralatan selama operasi

1) Apakah kemungkinan timbul kesulitan dalam 5. Oleh Ahli Bedah, Ahli Anesthesi dan Perawat :
Ya Tidak operasi ? Pesan khusus dari dokter bedah, dokter anestesi dan perawatan untuk perawatan di RR :
Apakah tindakan antisipasi telah disiapkan?

..............................................................................................................................................................................
5. Apakah pasien mempunyai riwayat alergi 2) Berapa estimasi lama operasi = ..............jam
..........................................................................................
6. Kesulitan bernafas / risiko aspirasi? Tersediakah
3) Perkiraan kehilangan darah ............ cc
peralatan / bantuan

7. Risiko kehilangan darah > 500 ml (7 ml / Kg BB pada

Bidang Anestesi
anak) Tanda Tangan

8. Dua akses intravena / akses sentral dan rencana terapi Adakah masalah khusus pada pasien ini dan Dokter Operator Dokter Anestesi

cairan langkah antisipasi?

Bidang Keperawatan

1) Sudahkan cek alat steril

Perawat Sirkuler Perawat Kamar Operasi

2) Adakah alat khusus

5. Sudahkah hasil MRI, CT-Scan, Foto Rontgen

terpasang ?