Operation Protocol — The WHO Surgical Safety Checklist — A Surgeon's Clinical Manual of Anorectal Disease

This appendix sets out a structured, fillable operation protocol. It is based on the World Health Organization's Surgical Safety Checklist. The World Health Organization introduced this checklist in 2008. It was part of the Safe Surgery Saves Lives programme. A large multi-country study followed, published in 2009. It showed that using this checklist reduced both death and major complications after surgery. Many hospitals worldwide have adopted it since.

The pages that follow are designed to be photocopied, or reproduced, and completed by hand for each patient. Resident doctors, on both the surgical and anaesthesia side, may fill this in together with the nursing team, at each stage of the patient's care.

Patient and Procedure Details

Patient's Name:		Ward/Bed No.:
I.P. No.:		UHID No.:
Age/Sex:		Date:
Name of Surgeon:		Name of Anaesthetist:
Procedure:		Unit:

E.1 Pre-Operative Preparation

Item	Yes	No
Written, informed consent taken, for surgery and anaesthesia
Pre-anaesthesia check-up completed
Nil by mouth confirmed, for the required period
Dentures, ornaments, nail polish, spectacles, and contact lenses removed
Operative site prepared and marked
Investigation reports attached to the case file

To be completed by the anaesthesia team, with the patient awake, before any anaesthetic drug is given.

Item	Yes	No
Patient's identity, surgical site, procedure, and consent confirmed
Surgical site marked, or marking confirmed as not applicable
Anaesthesia safety check complete
Pulse oximeter on the patient, and working
Known allergy checked
Difficult airway or aspiration risk assessed; help and equipment ready if needed
Risk of losing more than 500 ml blood (7 ml/kg in a child) assessed; access, fluids, or blood planned if needed

E.3 Time Out — Before Skin Incision

To be completed by the whole team together, immediately before the first incision. Each member introduces themselves, by name and role.

Item	Yes	No
Surgeon, anaesthetist, and nurse verbally confirm patient, site, and procedure
Surgeon has reviewed critical steps, operating time, and anticipated blood loss
Anaesthesia team has reviewed patient-specific concerns
Nursing team confirms sterility, including indicator results; equipment concerns reported
Antibiotic prophylaxis given in the last 60 minutes
Essential imaging displayed, where needed

E.4 Sign Out — Before the Patient Leaves the Operating Room

To be completed by the nurse, out loud, with the team, before the patient is moved out of the room.

Item	Yes	No
Name of the procedure, as actually performed, confirmed
Count of instruments, sponges, and needles confirmed correct
Any specimen correctly labelled, including patient's name
Equipment problems, if any, addressed
Key concerns for recovery reviewed by surgeon, anaesthetist, and nurse

E.5 Intra-Operative Monitoring and Documentation

Item	Yes	No
Vital signs monitored and recorded at regular intervals (pulse, blood pressure, oxygen saturation, end-tidal carbon dioxide, cardiac rhythm, temperature)
Every fluid and drug given, recorded with the time given
Instrument, sponge, gauze, and needle count performed before the operation
Count repeated at any relief of staff
Count repeated at closure
Final count performed; any discrepancy corrected and surgeon informed

E.6 Post-Operative Discharge Score (Recovery Room)

Score each row, and total the score before discharge from recovery. A commonly used cut-off for safe discharge is a total score of 9 or more, out of a maximum of 10.

Category	Finding	Score
Activity	Moves four extremities voluntarily / on command	2
	Moves two extremities	1
	Moves zero extremities	0
Respiration	Breathes deeply and coughs freely	2
	Dyspnoea, shallow or limited breathing	1
	Apnoeic	0
Circulation	Blood pressure ± 20 mm of pre-anaesthetic level	2
	Blood pressure ± 20–50 mm of pre-anaesthetic level	1
	Blood pressure ± 50 mm of pre-anaesthetic level	0
Consciousness	Fully awake	2
	Arousable on calling	1
	Not responding	0
Oxygen saturation	Maintains SpO₂ > 92% on room air	2
	Needs oxygen to maintain SpO₂ > 90%	1
	SpO₂ < 90% even with oxygen	0

Total Score:		Discharge Criteria Met (Yes/No):

Signatures

Name & Signature of Surgeon:		Date:
Name & Signature of Anaesthetist:		Date:
Name & Signature of Nurse:		Date:

E.7 Why This Appendix Matters

A checklist does not replace clinical judgement. It protects against ordinary, human errors. These can occur even in experienced hands. Examples include the wrong site, a missed allergy, a retained swab, or a simple break in communication between team members. The evidence for this simple tool is strong. Used consistently, it makes surgery safer, for every patient, in every operating room.

Operation Protocol — The WHO Surgical Safety Checklist