Surgical Safety Checklist

Surgical Safety Checklist – Ophthalmology (Based on WHO Surgical Check List)

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
Anaesthetist Sign Name:	Surgeon Sign Name:	Nurse Sign Name:

Pre Surgery Medication

Pre Surgery Tropical Plus Eye Drop

(Drop Every 10 Minutes 2 Times)

Post Surgery :

Moxiroot Eye Drop

Idylon Eye Drop

Amfinac OD Eye Drop

Dr Name

Dr Sign

Medication Order

Pre Surgery Tropical Plus Eye Drop

(Drop Every 10 Minutes 2 Times)

Date & Time

Nurse Name

Nurse Sign :