This printable surgical safety checklist follows the World Health Organization three-phase format for operating room teams. It is a two page template built for surgeons, anaesthetists, and nursing staff who want a paper checklist that stays at the point of care and can still be captured digitally. Case details sit at the top, and a sign-off section with space for notes closes the form.
What this survey measures
The checklist is organized into the three standard WHO phases. Sign In, before induction of anaesthesia, confirms patient identity, site, procedure and consent, site marking, the anaesthesia machine and medication check, the pulse oximeter, and any allergy, difficult airway, aspiration, or blood loss risk. Time Out, before skin incision, records team introductions, confirmation of the patient and incision site, antibiotic prophylaxis timing, anticipated critical events raised to the surgeon, anaesthetist, and nursing team, and whether essential imaging is displayed. Sign Out, before the patient leaves the operating room, captures the nurse's verbal confirmation of the procedure name, instrument, sponge and needle counts, specimen labelling, equipment problems, and key recovery concerns.
How to use it on paper
Print a copy for each case and keep it on the anaesthesia or circulating nurse's clipboard in theatre. Work through the phases aloud with the team and mark each item as it is confirmed. Use a blue or black pen so the marks scan cleanly. Collect the completed sheets at the end of the list, then scan or photograph them with PaperSurvey to turn every checked box into structured data automatically, no manual entry required.
Customize this template
Adapt the checklist with your clinical team to match local protocols while retaining the critical safety steps. Add your hospital logo and any additional checks your team needs. The layout reflows automatically as you edit.
Preview the PDF above, or use this template to start collecting responses today.