What is the WHO Surgical Safety Checklist?
The World Health Organization published the Surgical Safety Checklist in 2008 as part of its Safe Surgery Saves Lives programme. The original version has 19 items arranged in three phases. It was tested in hospitals in several countries with very different resources, and a study published in 2009 reported falls in complications and deaths after it was introduced. It has since been adopted around the world.
In England and Wales, a 2009 National Patient Safety Agency alert asked organisations to use the checklist for every patient having a surgical procedure. Most UK organisations now use an adapted local version. The National Safety Standards for Invasive Procedures 2 (NatSSIPs 2, 2023) extend the same principles to invasive procedures outside main theatres, such as endoscopy, interventional radiology, maternity and emergency departments.
What are the Five Steps to Safer Surgery?
UK teams usually learn the checklist as part of the Five Steps to Safer Surgery. The three middle steps are the WHO checklist phases. The brief and debrief wrap around the whole list.
| Step | When | Main purpose |
|---|---|---|
| 1. Team brief | Before the list starts, whole team present | Introductions, the plan for each patient, equipment and implants, staffing, and any concerns |
| 2. Sign in | Before induction of anaesthesia | Identity, procedure, site, consent and marking; anaesthetic safety checks; allergies, airway and bleeding risk |
| 3. Time out | Immediately before the incision or start of procedure, everyone stops | Final confirmation of patient, procedure and site; antibiotics, imaging, critical steps and concerns |
| 4. Sign out | Before any key team member leaves, usually before the patient leaves theatre | Procedure performed, counts, specimen labels, equipment problems and recovery plan |
| 5. Debrief | At the end of the list | What went well, what did not, and what needs fixing or escalating |
Local policy decides who leads each stage. Often a theatre nurse or operating department practitioner reads the checklist, but anyone can lead. What matters is that one named person leads, the operator, anaesthetist and scrub practitioner are all present and attentive, and each answer comes from the person who actually knows it.
What happens at sign in?
Sign in happens before induction of anaesthesia, ideally while the patient is awake and able to take part. It focuses on the patient and on anaesthetic safety.
- The patient states their name and date of birth, checked against the wristband and consent form.
- The patient says what operation they are having and on which side, and the site mark is checked.
- Consent is confirmed as present and correct.
- The anaesthetic machine and medicines check is confirmed, and monitoring such as pulse oximetry is working.
- Any known allergy is confirmed.
- The team confirms whether there is a known difficult airway or aspiration risk, with equipment and help available.
- The team confirms whether there is a risk of significant blood loss, with suitable access and blood products planned.
What is the time out in surgery?
Time out is the final check immediately before the first incision or the start of the procedure. Everyone stops what they are doing, music is turned down and the team gives the checklist its full attention. Many teams describe it as a 'hands off, eyes up' moment.
- Introductions: Team members confirm they know each other's names and roles, which makes it easier to speak up later.
- Patient, procedure and site: The operator confirms these aloud with the site mark visible, not hidden under drapes.
- Antibiotic prophylaxis: The team confirms whether antibiotics have been given within the time set by local policy, with the answer coming from the anaesthetist who gave them.
- Surgeon's concerns: Critical or unexpected steps, expected duration and anticipated blood loss.
- Anaesthetist's concerns: Any patient-specific issues for the procedure.
- Scrub practitioner's checks: Sterility confirmed and any equipment issues or concerns raised.
- Imaging: Essential images are displayed and confirmed as belonging to this patient and showing the correct side.
Grace, an operating department practitioner, is leading the time out for removal of metalwork from a left ankle. The registrar confirms 'left ankle' and the mark is visible. When Grace asks whether the essential imaging is displayed, she looks at the screen rather than accepting a quick 'yes'. The radiograph shows metalwork in a right ankle. The team stops. The images turn out to belong to another patient with a similar name. The correct images are displayed and checked, the procedure goes ahead, and the near miss is reported. The check worked because it was treated as a real question.
What is checked at sign out?
Sign out happens before the patient leaves the operating room, and before the surgeon or anaesthetist leaves. It is the phase most often rushed or skipped, which is a problem because it is where retained items and specimen errors are caught.
- The name of the procedure actually performed is confirmed aloud, since it may differ from the one planned.
- Counts of swabs, sharps and instruments are confirmed as complete and correct.
- Specimens are labelled correctly, with each label read aloud, including the patient's name and the site.
- Any equipment problems are recorded so they can be addressed.
- The surgeon, anaesthetist and practitioner agree the key concerns and plan for recovery.
'Specimens all labelled? Great. Counts correct? Lovely. Thanks everyone.'
'Specimen one, left forearm, patient name and hospital number checked. Specimen two, back, same details. Counts of swabs, sharps and instruments are complete and correct. Procedure performed was excision of two skin lesions. Any equipment issues? Any concerns for recovery?'
Reading each label aloud gives the surgeon a chance to say 'no, the larger lesion was from the back'. A specimen mix-up that is not caught can lead to the wrong site being treated after the histology result.
Why does the checklist sometimes fail?
The checklist is simple, but using it well is not. Investigations and audits in the UK describe the same weaknesses again and again. A signed checklist does not prove the checks happened, which is why many organisations now audit by observing practice rather than reviewing forms alone.
| Problem | What it looks like | What helps |
|---|---|---|
| Tick-box use | Items read quickly with automatic 'yes' answers | Ask questions that need a real answer, such as 'Which side?' |
| Key people absent | Time out starts while the consultant or anaesthetist is out of the room | Do not start until everyone needed is present and attentive |
| Distraction | Music, conversation, phones, setting up equipment | A clear pause where all activity stops |
| Hierarchy | Junior staff do not challenge a senior who wants to start | Seniors invite challenge and thank people who raise concerns |
| Time pressure | Checks shortened on a delayed list | Treat the checklist as part of the procedure, not an extra |
| Normalised shortcuts | Small deviations accepted because nothing has gone wrong yet | Observed audit and honest debriefs |
| Answering for others | One person answers questions that belong to another team member | Each answer comes from the person who knows |
How do you speak up during the checklist?
Every member of the theatre team has a professional duty to raise a patient safety concern, whatever their grade or profession. Both the GMC and the NMC are clear about this. In practice, challenging a senior colleague can feel very hard, particularly if you are new to the team or new to the NHS. Structured, graded language helps.
- Probe: Ask a question: 'Can I check the side? I thought the consent said right.'
- Alert: State the concern and the risk: 'The mark and the consent don't match. We could be about to operate on the wrong side.'
- Challenge: Ask directly for action: 'I need us to stop and check the notes before we start.'
- Emergency: Stop the procedure: 'Stop. I am not happy for this to continue until the side is confirmed.' Then escalate to the most senior person available or the theatre coordinator.
Many departments agree a stop phrase, such as 'I have a safety concern', that everyone recognises. Find out whether yours has one. If you are the senior person, respond to a challenge with thanks and a check, even when you are sure you are right. How you respond to the first concern decides whether the next person speaks up.
Reflecting on your own checklist practice
A useful question to ask yourself after any list is not 'did I sign it?' but 'did the check really happen?' Did you answer a question that belonged to someone else? Did a time out start before everyone was ready? Did sign out happen before the surgeon left? Small, honest observations like these make good material for a reflective account, appraisal or revalidation.
If you have been involved in an incident linked to the checklist, be open with the patient, report it, and take part in the review. If your regulator becomes involved, seek advice from your defence organisation, trade union or legal representative before responding.
Our course WHO Surgical Safety Checklist in Practice covers the brief, sign in, time out, sign out and debrief in more detail, with worked examples, human factors, practical speaking-up language and a guided reflection. It is suitable for surgeons, anaesthetists, theatre nurses, operating department practitioners and anyone who performs or assists with invasive procedures.
Frequently asked questions
What are the three phases of the WHO Surgical Safety Checklist?
The three phases are sign in, done before induction of anaesthesia; time out, done immediately before the skin incision or start of the procedure; and sign out, done before the patient leaves the operating room. UK practice adds a team brief before the list and a debrief at the end, making the Five Steps to Safer Surgery.
Who should lead the WHO checklist?
Local policy decides. Often a registered practitioner such as a theatre nurse or operating department practitioner leads, but any team member can. The essential points are that one named person leads, the operator, anaesthetist and scrub practitioner are present and engaged, and each question is answered by the person who actually knows the answer.
Is the WHO checklist mandatory in the UK?
A 2009 National Patient Safety Agency alert asked organisations in England and Wales to use the checklist for every patient having surgery, and NatSSIPs 2 sets national standards for all invasive procedures. Each organisation sets its own policy and local version, and following it is part of your professional duty to keep patients safe. Check your local policy for exact requirements.
What is checked at sign out?
At sign out the team confirms aloud the procedure actually performed, that counts of swabs, sharps and instruments are complete and correct, that specimens are labelled correctly (reading each label aloud including the patient's name), any equipment problems, and the key concerns and plan for recovery. It should happen before the surgeon or anaesthetist leaves the room.
Can the checklist be changed locally?
Yes. The WHO intended the checklist to be adapted to local practice, and most UK organisations add items such as VTE prophylaxis, glycaemic control, warming or implant checks. Core items should not be removed. Always use your organisation's current version rather than a generic template found online.
What should I do if the time out is being rushed?
Ask for the team to pause until everyone needed is present and attentive. Use clear language, such as 'Can we wait for the anaesthetist before we do the time out?' If you are not heard, escalate using graded assertiveness or your department's agreed stop phrase, then involve the theatre coordinator. Report persistent problems through your incident or concerns process.
Does the checklist apply outside the operating theatre?
The principles do. NatSSIPs 2 expects organisations to have local safety standards (LocSSIPs) for invasive procedures in settings such as endoscopy, interventional radiology, delivery suites, emergency departments, clinics and wards. These keep the core checks of correct patient, procedure, site and equipment, plus a final check of counts and specimens.
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Sources and further reading
- Surgical Safety Checklist and Implementation Manual. World Health Organization.
- National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). Centre for Perioperative Care.
- Good Surgical Practice. Royal College of Surgeons of England.
- Good Medical Practice (2024). General Medical Council.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- Raising and acting on concerns about patient safety. General Medical Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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