WHO Safety Checklist
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The WHO Surgical Safety Checklist Made Simple
What it is, why it exists, where it is used, and how to complete all three phases correctly every time.
- What is the WHO Surgical Safety Checklist?
- Why it was created and the evidence behind it
- Where it is used across the world and the NHS
- The three phases: Sign In, Time Out and Sign Out
- How to complete the checklist correctly
- Tips for students and new theatre staff
What Is the WHO Surgical Safety Checklist?
The WHO Surgical Safety Checklist is a standardised tool developed by the World Health Organization (WHO) to reduce preventable harm during surgical procedures. It was launched in 2008 as part of the Safe Surgery Saves Lives campaign and has since become one of the most widely adopted patient safety tools in the world.
The checklist is divided into three phases that correspond to three specific moments during every surgical procedure. These are before anaesthesia, before the first incision, and before the patient leaves the operating theatre. At each phase, a designated team member (usually the circulating nurse or ODP) reads out a series of questions that the whole theatre team confirms together.
The checklist is not a box ticking exercise. It is a structured team communication tool. Done properly, it creates a moment of shared focus where every member of the theatre team including the surgeon, anaesthetist, ODP, scrub nurse and circulator is on the same page before proceeding.
Developed by the World Health Organization in 2008. Now used in over 90% of countries worldwide.
Sign In before anaesthesia, Time Out before incision, and Sign Out before the patient leaves theatre.
Read aloud by one person and confirmed by the whole team. Every discipline has an active role.
Mandatory in all NHS hospitals in England. Embedded in the NHS England Safety Standards for Invasive Procedures (SSEPs).
Why Was It Created?
Surgery saves millions of lives each year but it also carries significant risk. Before the checklist existed, surgical complications from preventable errors including wrong site surgery, retained instruments, avoidable infections and anaesthetic mishaps were alarmingly common across all healthcare systems, including well funded ones.
The WHO piloted the checklist in eight hospitals across eight countries. The results were striking. The rate of major complications fell significantly and deaths dropped in every single site studied. It demonstrated that a simple, structured verbal check before and after surgery could save lives regardless of hospital size or country income level.
Confirming the site, side and procedure with the whole team before incision catches errors before they happen.
Introductions and briefings break down hierarchy and make it safer for any team member to raise a concern.
Confirming antibiotic prophylaxis has been given within the correct time window significantly reduces surgical site infections.
Checking equipment, allergies and the anaesthetic plan before induction reduces avoidable critical incidents.
The checklist only works if it is completed properly as a real team interaction. It should never be rushed through or completed in advance. Research shows that checklists completed as a formality without genuine team engagement do not produce the same safety benefits. Every question matters.
Where Is the Checklist Used?
The WHO Surgical Safety Checklist was designed to be adaptable across all surgical settings, from major tertiary centres to district general hospitals. In the UK, completing the checklist is a mandatory requirement for all invasive procedures under NHS England's Safety Standards for Invasive Procedures (SSEPs).
Many trusts have adapted the WHO checklist to create their own local version. The three-phase structure and core content remain consistent with the WHO template. Always follow your specific trust's version of the checklist as local adaptations may include additional checks relevant to your setting.
Sign In, Time Out and Sign Out
The checklist is divided into three distinct phases. Each phase happens at a critical transition point during the patient's journey through theatre. Here is what each phase covers and when it takes place.
- Patient has confirmed their identity, site, procedure and consent
- Surgical site has been marked where applicable
- Anaesthesia safety check has been completed
- Pulse oximeter is functioning and attached to the patient
- Any known patient allergies have been confirmed and documented
- Difficult airway or aspiration risk has been identified with equipment and assistance available
- Risk of blood loss greater than 500ml (7ml/kg in children) has been assessed with adequate IV access and fluids planned
- All team members have introduced themselves by name and role
- Surgeon, anaesthetist and nurse have verbally confirmed patient identity, site and procedure
- Surgeon has confirmed anticipated critical events including key steps, expected blood loss and any special equipment required
- Anaesthetic team have confirmed any patient-specific concerns
- Nursing team have confirmed sterility of instruments and any equipment concerns
- Antibiotic prophylaxis has been given within the last 60 minutes and confirmed by the team
- Relevant imaging is displayed and available in theatre
- VTE prophylaxis plan has been confirmed where applicable
- Nurse verbally confirms the name of the procedure that was performed
- Instrument, swab and needle count is correct or any discrepancy has been documented
- Specimen labelling has been confirmed with the patient's details applied in their presence
- Any equipment problems have been identified and will be addressed
- Surgeon, anaesthetist and nurse have reviewed key concerns for recovery and post-operative management
- VTE risk assessment and prophylaxis plan have been reviewed and handed over
The checklist must be paused and completed properly at each transition point. It should never be rushed or completed while other tasks are ongoing. The Time Out in particular requires the whole team to stop what they are doing and actively participate. This is known as a hard stop.
How to Complete the Checklist Correctly
In most theatres, the circulating nurse or ODP takes the lead on reading out the checklist. Here is how to approach it with confidence.
Your hospital will have its own adapted checklist. Familiarise yourself with it before you are in theatre. The three-phase structure is universal but the exact questions and order may differ slightly from the WHO original.
Have the checklist form ready and accessible. Confirm you know the patient's name, date of birth, procedure and site before they come into the anaesthetic room. Check consent forms and the patient's notes in advance.
Read each question at a steady pace and do not rush. When you ask if something has been confirmed, wait for a clear verbal response from the relevant team member. Do not accept a nod or silence. If a question is not answered, ask again.
Before skin incision you must get the whole team's attention. It is acceptable and expected to say "Can we stop for the Time Out please?" even to a consultant surgeon. This is a patient safety requirement, not a suggestion.
Sign and time stamp the checklist form at each phase. Document any concerns raised and how they were resolved. The completed checklist forms part of the patient's legal theatre record and must be accurate and legible.
If a check fails and consent is missing, the site is not marked, or the swab count does not tally, you must say so. The checklist gives every team member the authority and the responsibility to raise a concern. A good team culture means you will always be heard.
Roles in the Checklist
Every member of the theatre team has a defined role during the checklist. Understanding your role and those of your colleagues helps the process run smoothly and safely.
Typically leads the checklist. Reads out each item, coordinates responses and records the outcome on the form.
Confirms the anaesthetic safety check, patient allergies, airway risks and any anaesthetic concerns during the Time Out.
Confirms patient identity, site, procedure and critical steps. Leads the surgical review during the Time Out.
Confirms sterility of instruments and equipment availability. Performs the swab, instrument and needle count at Sign Out.
Key Things to Remember
If you are new to theatre or on placement, here are the most important things to keep in mind about the WHO checklist.
As a student you may not be the one leading the checklist but you should follow along every time. Use each checklist as a learning opportunity. Notice how different teams communicate and observe the difference in safety culture when the checklist is done well versus when it is rushed. If you spot something that has not been picked up, it is absolutely appropriate to raise it politely.
Read your trust's checklist form before your first placement. Knowing what is on it means you can follow the process confidently from day one.
Even in emergencies a rapid version of the checklist should be completed. There is no surgical case where patient safety checks become optional.
The checklist gives you the authority to raise a concern. If you notice something has been missed, say so. Your observation could prevent a serious incident.
If you are responsible for the form, write legibly, sign and time stamp each phase and record any issues raised during the checks.
Healthcare Accessories for Every Shift
Badge reels, fob watches, compression stockings and more. Designed by an NHS ODP.