Surgical Safety Checklist

Surgical Safety Checklist – Ophthalmology

Date & Name & Site of Surgery: _________________________________________

Before Anesthesia Sign in	Before Incision Time out	Before leaving operating room Sign out
Patient Has Confirmed ☐ Identity ☐ Site ☐ Procedure ☐ Consent ☐ Site marked ☐ History & physical reviewed ☐ Presurgical assessment complete ☐ Preanesthesia assessment complete ☐ Anesthesia safety check done Does patient have: Difficult airway/aspiration risk? ☐ Not applicable ☐ No ☐ Yes: equipment/assistance available History of Flomax/alpha 1-a inhibitor? ☐ No ☐ Yes History of anticoagulants? ☐ No ☐ Yes ☐ Continued ☐ Stopped as instructed	☐ All team members have introduced themselves by name and role Surgeon, anesthesia provider and nurse orally confirm: ☐ Patient ☐ Site ☐ Procedure Surgeon and nurse orally confirm: ☐ Antibiotic ☐ Mitomycin-c/anti-neoplastic ☐ Implant style and power ☐ Devices ☐ Tissue ☐ Gas ☐ Dyes Anticipated critical events Surgeon reviews ☐ Critical or unexpected steps ☐ Reviewed ☐ None anticipated ☐ Operative duration Anaesthesia provider reviews ☐ Any patient-specific concerns Nursing team reviews ☐ Sterility (including indicators results) ☐ Equipment issues ☐ Concerns	Nurse orally confirms with team ☐ Name of procedure recorded ☐ Instrument, sponge, sharp count correct ☐ Yes ☐ Not applicable ☐ Specimen labeled (including patient name) ☐ Yes ☐ Not applicable ☐ Equipment issues addressed Surgeon, anaesthesia provider and nurse ☐ Key concerns for recovery and management of patient reviewed
Check by Sign Name:___________________________	Anaesthetist Sign Name:___________________________	Surgeon Sign Name:___________________________