Who checklist and safety culture

Why this matters (for anaesthesia starters)

• Most serious peri-operative harm is linked to communication failures, wrong assumptions, or missed steps—not lack of knowledge.
• The WHO Surgical Safety Checklist is a structured team pause to catch predictable errors (patient, procedure, site, airway, allergies, blood, antibiotics, equipment).
• Safety culture is “how we do things here when it comes to safety”: speaking up, listening, and acting on concerns.
• Your role: be an active participant, not a passive observer—especially during Sign In and Time Out.

WHO Surgical Safety Checklist: the 3 phases (what they are)

• Sign In (before induction of anaesthesia): confirm patient identity, procedure, site/side, consent, allergies, airway/aspiration risk, monitoring, equipment, IV access, blood availability if needed.
• Time Out (before skin incision): whole team pause; confirm identity/procedure/site, antibiotics, imaging, anticipated critical events (surgeon/anaesthetist/nursing), sterility, VTE prophylaxis plan if relevant.
• Sign Out (before patient leaves theatre): confirm procedure done, instrument/swab counts, specimen labelling, key post-op plans (analgesia, PONV, fluids, antibiotics, destination, concerns).

Sign In: anaesthetic-focused essentials

• Identity and consent: check name, DOB/NHS number (or local identifier), procedure, side/site marking, and that consent matches the plan.
• Allergies and reactions: clarify what happened (rash vs anaphylaxis), and ensure allergy band and drug chart are consistent.
• Airway and aspiration risk: brief plan A/B (and who is helping), consider fasting status, reflux, obesity, pregnancy, bowel obstruction; decide on RSI if indicated.
• Monitoring and equipment: pulse oximeter on and working; suction, oxygen supply, ventilator check, airway kit, difficult airway equipment if needed, capnography for any airway device.
• IV access and drugs: confirm working cannula, plan for additional access/arterial line if needed, emergency drugs available (including vasopressors).
• Blood and haemorrhage planning: group & screen/crossmatch if indicated; cell salvage/major haemorrhage protocol awareness; warming plan.
• Team readiness: ask if anyone has concerns before starting.

Time Out: making it a real safety pause (not a tick-box)

• Stop other tasks: pause drug drawing, positioning, prepping—give full attention for 30–60 seconds.
• Introduce names/roles if unfamiliar: especially important with rotating staff and emergencies.
• Confirm: patient, procedure, site/side, position, tourniquet (if used), implants, imaging displayed (correct patient/side).
• Antibiotics: correct drug, dose, and timing (usually within 60 minutes of incision; follow local policy). Document if not given and why.
• Anaesthetic critical events: share airway plan, aspiration risk, haemodynamic concerns, planned lines, blood loss risk, and any special monitoring.
• Invite challenge: explicitly say “Please stop us if anything doesn’t match.”

Sign Out: protecting the handover

• Confirm procedure performed and any intra-op changes (e.g., converted to open, unexpected findings).
• Counts and specimens: ensure swab/needle/instrument counts are correct; specimens labelled with patient details and site; request forms completed.
• Post-op plan: analgesia (including blocks/catheters), antiemetics, antibiotics, fluids, oxygen/ventilation plan, thromboprophylaxis plan if relevant, destination (PACU/HDU/ICU) and triggers to escalate.
• Handover quality: use a structured approach (e.g., SBAR) and include key events (difficult airway, hypotension, bleeding, anaphylaxis, awareness risk).

Safety culture: behaviours that matter on day 1

• Speak up early: raise concerns when they are small (wrong side mark, missing blood, unclear consent, no antibiotics).
• Be specific and calm: state the concern, the risk, and what you need (“I’m worried this is the wrong side; can we re-check the consent and mark before we start?”).
• Closed-loop communication: ask for confirmation and repeat back critical information (drug doses, blood loss, antibiotic given).
• Flatten hierarchy: invite others to challenge you; thank people for speaking up.
• Human factors basics: fatigue, distractions, noise, and time pressure increase errors—use the checklist to slow down at the right moments.

Common first-time scenarios (what to do)

• Patient arrives without wristband / details mismatch: stop; confirm identity with multiple sources; involve nurse-in-charge; do not induce until resolved.
• Consent unclear or procedure differs from list: stop; contact surgeon; confirm with patient if possible; document; do not proceed until aligned.
• No site mark for laterality procedure: stop; request marking by appropriate clinician per local policy; do not proceed.
• Antibiotics not prescribed or delayed: flag at Time Out; agree plan; document reason if omitted; consider redosing for long cases per policy.
• Known difficult airway but kit not present: stop; get equipment and skilled help; agree plan and backup; consider awake technique if appropriate.
• Emergency case pressure: still do a rapid checklist (“minimum safe pause”); focus on identity, procedure/site, allergies, airway, blood, antibiotics, equipment.

Practical tips to make the checklist work

• Be present and audible: stand where you can be heard; make eye contact with the team lead.
• Use your own mini-prompt: Identity–Allergies–Airway–Aspiration–Access–Blood–Antibiotics–Equipment–Destination.
• If something is wrong, use a clear stop phrase: “I’m not happy to proceed until we’ve clarified X.”
• Document key items as you go (antibiotic time, airway grade, lines, complications) to support safe Sign Out and PACU handover.