Standard 2 · applies to facilities with an operating theatre
Operating Theatre and Surgical Safety
Three criteria for operating theatres: the surgical safety checklist and team pause, anaesthesia safety and monitoring, and the surgical site infection prevention bundle. Most documents are theatre-specific (SRG-); the rest are existing identification, hand hygiene, medicines and infection surveillance documents, reused where the process is the same.
Two kinds of document
Means of verification. The policies, registers, forms and plans the surveyor checks. The organisation submits them.
Recommended. SOPs and guidelines that support good practice. They are held on site but are not verified.
How a surveyor reads each criterion
Why it matters→
Sample→
Method and evidence→
Pass ruleor
Immediate fail
How strict is Standard 2, by setting
Each row adds up to the total number of criteria on this page.
Non-negotiable
WHO's Surgical Safety Checklist is completed, out loud, as a team pause for every procedure — not filed as paperwork after the fact — and includes explicit verification of correct patient, correct procedure, and correct body site, with the site physically marked before the patient enters theatre.
Why this criterion matters. The surgical safety checklist works only when the team says it out loud, together, at each pause. A checklist filed after the operation protects no one.
Sample. Observe 5 procedures on the day of assessment, or from the last month if none are running. For each, check the checklist record for all three pauses. Check the team's spoken confirmation at the time-out.
How the surveyor verifies this
1. The checklist is completed aloud at all three pauses.
Method. Observe the pauses for each of the 5 procedures and check the record.
Evidence to show. Surgical safety checklist record (SRG-FRM-001).
Pass when. At least 90% of procedures show all three pauses completed aloud.
2. Patient, procedure and site are confirmed aloud at the time-out.
Method. Listen for the confirmation of each item at the time-out.
Evidence to show. Observed time-out.
Pass when. Every observed time-out confirms patient, procedure and site aloud.
3. Identity is checked against the identification log.
Method. Check the patient identification log for each of the 5 procedures.
Evidence to show. Patient identification check log (ID-FRM-001).
Pass when. Every sampled procedure has an identity check recorded.
Immediate fail (any one means the criterion is not met)
- A procedure starts with no time-out, or the checklist is completed after the patient has left the theatre.
Documents
Means of verification. The surveyor checks these. Submit them.
- SRG-POL-001 · Surgical safety checklist and team pause
Why it is here. The checklist and the team pause rule for every procedure.
Submit the approved policy with version and date, and evidence it is in use. - SRG-FRM-001 · Surgical safety checklist record
Why it is here. The checklist completed at each pause.
Submit the completed form for the sample period. - ID-FRM-001 · Patient Identification Check Log
Why it is here. The identity check at the start of each case (existing standard form, reused).
Submit the completed form for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
- SRG-SOP-001 · Surgical safety checklist procedure
Why it is here. How the checklist is run, item by item.
E-learning
- Ophthalmology & Day Surgery Safety (AMB-15)
- Care & Treatment: Clinical Standards for Accreditation (H-04)
- Planned course: Surgical safety checklist and team pause. New course planned.
References
- World Health Organization (2009). WHO Surgical Safety Checklist and Implementation Manual. Geneva: WHO.
- World Health Organization (2008). Safe Surgery Saves Lives: WHO Guidelines for Safe Surgery. Geneva: WHO.
Non-negotiable
Anaesthesia follows defined safety protocols with continuous monitoring throughout the procedure, appropriate to the level of anaesthesia and the patient's specific risk profile.
Why this criterion matters. Anaesthesia is the highest-risk part of the day for many patients. Continuous monitoring through the whole procedure, matched to the level of anaesthesia, is the standard that finds the problem early.
Sample. Review 10 anaesthesia records from the last month, and check the machine check records for the last 30 days.
How the surveyor verifies this
1. Anaesthesia follows a written protocol.
Method. Read the anaesthesia protocol and check its review date.
Evidence to show. Anaesthesia safety policy (SRG-POL-002).
Pass when. The protocol is current and approved by the lead anaesthetist.
2. The patient is monitored continuously from induction to recovery.
Method. Check each of the 10 records for monitoring at the set interval through the case.
Evidence to show. Anaesthesia record and monitoring chart (SRG-FRM-002).
Pass when. At least 90% of records show continuous monitoring.
3. Anaesthetic equipment is checked before each list.
Method. Check the machine check record for each list in the last 30 days.
Evidence to show. Anaesthesia machine and equipment check (SRG-FRM-003).
Pass when. At least 90% of lists have a recorded check before the first case.
Immediate fail (any one means the criterion is not met)
- A patient is anaesthetised with no monitoring, or on equipment that has not been checked.
Documents
Means of verification. The surveyor checks these. Submit them.
- SRG-POL-002 · Anaesthesia safety and monitoring
Why it is here. The anaesthesia protocol and monitoring standard.
Submit the approved policy with version and date, and evidence it is in use. - SRG-FRM-002 · Anaesthesia record and monitoring chart
Why it is here. The record of monitoring from induction to recovery.
Submit the completed form for the sample period. - SRG-FRM-003 · Anaesthesia machine and equipment check
Why it is here. The daily check of the anaesthetic machine and equipment.
Submit the completed form for the sample period. - HOS-POL-001 · Medicines management policy
Why it is here. The medicines rules for anaesthetic drugs (existing policy, reused).
Submit the approved policy with version and date, and evidence it is in use.
E-learning
- Emergency Medical Equipment & AED Readiness (MED-02)
- Care & Treatment: Clinical Standards for Accreditation (H-04)
- Planned course: Anaesthesia monitoring and equipment check. New course planned.
References
- American Society of Anesthesiologists (2020). Standards for Basic Anesthetic Monitoring. Schaumburg, IL: ASA.
Non-negotiable
A defined surgical site infection prevention bundle is followed for every procedure — a specific, checkable set of practices, not general good intentions about cleanliness.
Why this criterion matters. Infections after surgery are preventable with a set of checkable practices. A bundle, followed for every procedure and measured, is what makes prevention real.
Sample. Review the compliance record for the last 3 months, the surgical site infection register for the same period, and 10 procedures.
How the surveyor verifies this
1. Each procedure follows the bundle.
Method. Check the bundle compliance record for each of the 10 procedures.
Evidence to show. Surgical site infection bundle compliance record (SRG-FRM-004).
Pass when. At least 90% of procedures have every part of the bundle recorded as done.
2. Antibiotic prophylaxis is given within the set window.
Method. Check the antibiotic time against the incision time for each procedure.
Evidence to show. Anaesthesia record and bundle record.
Pass when. At least 90% of antibiotic doses are given within the set window.
3. Surgical site infections are tracked and reviewed.
Method. Check the surveillance register and the review record for the period.
Evidence to show. Healthcare-associated infection surveillance register (HOS-REG-005).
Pass when. Every infection is recorded and reviewed within 7 days.
Immediate fail (any one means the criterion is not met)
- A procedure starts without the bundle, or a surgical site infection is found with no review.
Documents
Means of verification. The surveyor checks these. Submit them.
- SRG-POL-003 · Surgical site infection prevention
Why it is here. The surgical site infection prevention rule.
Submit the approved policy with version and date, and evidence it is in use. - SRG-FRM-004 · Surgical site infection bundle compliance record
Why it is here. Records whether each part of the bundle was done.
Submit the completed form for the sample period. - HOS-REG-005 · Healthcare-associated infection surveillance register
Why it is here. The infection surveillance register (existing register, reused).
Submit the register extract for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
- SRG-SOP-003 · Surgical site infection prevention bundle
Why it is here. The bundle, step by step. - HH-SOP-001 · Hand Hygiene at the Point of Care
Why it is here. Hand hygiene at the point of care (existing procedure, reused). - HOS-SOP-014 · Healthcare-associated infection surveillance and response
Why it is here. How infections are reviewed and acted on (existing procedure, reused).
E-learning
References
- World Health Organization (2018). Global Guidelines for the Prevention of Surgical Site Infection, second edition. Geneva: WHO.