Standards › ASF Health Standards Version 11 › Standard 7
Standard 7
Surgical and Procedural Safety
Surgical and procedural care is made safe through the surgical safety checklist, safe anaesthesia, prevention of surgical site infection, procedures performed within privileges, safe recovery and complete instrument, swab and sharps counts.
How to read the colours
Red: Must. Required in every setting. Criteria that protect life are always red.
Green: Medium. Required, adapted to what a humanitarian or transition setting can realistically do.
Yellow: Minimum. The lowest acceptable level in a humanitarian setting, where resources are very limited.
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Every policy, SOP, form and course on this page is a draft to help you. Adapt it to your hospital, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how.
7.1The Surgical Safety Checklist Is UsedHumanitarian settings: MustTransition and fragile: MustStandard: Must
The WHO Surgical Safety Checklist is completed out loud, as a team, at three pauses: before induction of anaesthesia, before skin incision, and before the patient leaves the operating room.
Why it matters. The checklist works only when the team says it out loud at each pause. A checklist completed after the operation protects no one.
Questions the surveyor asks
- Is the checklist completed out loud at all three pauses? Sign-in, time-out and sign-out, not just one of them.
- Does every team member take part? A checklist read by one person to a silent room misses its purpose.
- Is there evidence that the checklist has changed a decision or caught an issue? A checklist that never catches anything is worth questioning, not just checking for completion.
How the surveyor verifies this criterion
Sample. Observation of 10 procedures across two weeks, and the completed checklist records for the last 3 months.
1. Three pauses done out loud
Method. Observe 10 procedures and note each pause.
Evidence to show. Completed checklist record (SRG-FRM-001) and an observation record.
Pass when. All three pauses are completed out loud in at least 9 of the 10 observed procedures.
2. Team takes part
Method. Observe who responds at each pause.
Evidence to show. Observation record.
Pass when. At least the surgeon, anaesthetist and nurse respond at each pause.
3. Records are complete
Method. Check the last 3 months of checklist records.
Evidence to show. Completed SRG-FRM-001 records.
Pass when. Every record is signed by the team leader at all three pauses.
Good practice. The checklist is spoken out loud at all three pauses, with the whole team taking part.
Immediate fail (any one means the criterion is not met). The checklist is signed after the operation with no pause during the procedure.
Partial because. The team does not all join, or the checklist is completed after the procedure.
Staff, training and documents
Documents
- SRG-POL-001 Surgical safety checklist and team pause
- SRG-SOP-001 Surgical safety checklist procedure
- SRG-FRM-001 Surgical safety checklist record
E-learning
- Ophthalmology & Day Surgery Safety (Must for theatre staff)
- WHO Surgical Safety Checklist and team pause, for field teams (New course planned)
7.2Anaesthesia Is Delivered SafelyHumanitarian settings: MustTransition and fragile: MustStandard: Must
Anaesthesia follows a written safety protocol, with monitoring throughout the procedure matched to the level of anaesthesia and the patient’s risk.
Why it matters. Anaesthesia is the highest-risk part of many procedures. Continuous monitoring through the whole procedure finds problems early, while there is still time to act.
Questions the surveyor asks
- Is monitoring continued through the whole procedure, including emergence? Gaps in the middle of a long procedure are a documented risk pattern.
- Is the equipment present, working and checked before use? Equipment that is present but not checked gives false reassurance.
- Is there an escalation protocol for anaesthesia complications? A protocol for a routine case is not the same as a protocol for when something goes wrong.
How the surveyor verifies this criterion
Sample. Ten anaesthesia records from the last 3 months, and the anaesthesia machine check log for the same days.
1. Monitoring is recorded throughout
Method. Check each record for monitoring entries at induction, during the procedure and at emergence.
Evidence to show. Anaesthesia record and monitoring chart (SRG-FRM-002).
Pass when. Monitoring is recorded at least every 5 minutes in all sampled records.
2. Equipment is checked before each list
Method. Check the machine check log for each sampled day.
Evidence to show. Anaesthesia machine and equipment check (SRG-FRM-003).
Pass when. A completed check is recorded before the first case of each sampled day.
3. Escalation is known
Method. Ask an anaesthetist and a nurse to explain the steps for a sudden fall in oxygen saturation.
Evidence to show. Anaesthesia safety and monitoring policy (SRG-POL-002).
Pass when. Both describe the same steps, and the steps match the policy.
Good practice. Monitoring recorded at least every 5 minutes, with the equipment checked before each list.
Immediate fail (any one means the criterion is not met). A ventilated or sedated patient is monitored with alarms switched off or with no monitoring recorded.
Partial because. Monitoring is recorded at irregular intervals, or the equipment is checked but the log is not completed.
Staff, training and documents
Documents
- SRG-POL-002 Anaesthesia safety and monitoring
- SRG-FRM-002 Anaesthesia record and monitoring chart
- SRG-FRM-003 Anaesthesia machine and equipment check
- AES-SOP-003 Sedation and anaesthesia safety
- DAY-SOP-002 Sedation and anaesthesia level, and response to complications
E-learning
- Ophthalmology & Day Surgery Safety (Must for anaesthesia and sedation staff)
7.3Surgical Site Infection Is Actively PreventedHumanitarian settings: MediumTransition and fragile: MediumStandard: Must
The surgical site infection (SSI) prevention bundle is applied to every procedure: antibiotic prophylaxis given at the right time, skin preparation with an approved antiseptic, hair removed only when it would interfere with surgery, normal body temperature and blood glucose control.
Why it matters. Surgical site infection is one of the most common complications of surgery. Most cases can be prevented with a short set of measures applied every time.
Questions the surveyor asks
- Is antibiotic prophylaxis given within the recommended window before incision? Timing matters as much as the choice of drug.
- Is the skin prepared with an approved antiseptic, and is hair removed only when needed? Routine shaving increases the risk of infection.
- Are surgical site infections recorded and reviewed? A rate that is not known cannot be improved.
How the surveyor verifies this criterion
Sample. Twenty procedures from the last 3 months, with the bundle record and the infection log.
1. Bundle recorded for each procedure
Method. Check the bundle record for each sampled procedure.
Evidence to show. SSI bundle compliance record (SRG-FRM-004).
Pass when. The bundle is recorded for at least 18 of 20 sampled procedures.
2. Antibiotic given on time
Method. Compare the time of the antibiotic dose with the time of incision.
Evidence to show. Anaesthesia record (SRG-FRM-002).
Pass when. Given within the window in SRG-SOP-003 in at least 18 of 20 procedures.
3. Infections are reviewed
Method. Check the infection log and the review minutes for the last 3 months.
Evidence to show. SSI log and review minutes.
Pass when. Every infection is logged and reviewed at least every quarter.
Good practice. The bundle is recorded, antibiotic timing is checked, and infections are reviewed every quarter.
Immediate fail (any one means the criterion is not met). No surveillance of surgical site infections is in place.
Partial because. The bundle is used but not recorded, antibiotic timing is not checked, or surveillance is done only once a year.
Staff, training and documents
Documents
- SRG-POL-003 Surgical site infection prevention
- SRG-SOP-003 Surgical site infection prevention bundle
- SRG-FRM-004 Surgical site infection bundle compliance record
- SRG-SOP-002 Surgical site marking and patient identification before every operation
- HH-SOP-001 Hand hygiene at the point of care
- IPC-POL-001 Infection prevention and control programme
E-learning
- Ophthalmology & Day Surgery Safety (Must for theatre staff)
7.4Procedures Are Performed Within Granted Privileges and Marked CorrectlyHumanitarian settings: MediumTransition and fragile: MustStandard: Must
Each surgeon operates only within the privileges granted by the facility. The operating list is checked against those privileges before the day starts, and the operative site is marked and verified before every operation.
Why it matters. Wrong-site, wrong-procedure and operations by staff without the right training are among the most serious patient safety events. Clear privileges and site marking prevent them.
Questions the surveyor asks
- Does each surgeon have a current privilege list? A verbal assurance is not evidence.
- Is the operating list checked against privileges before the day starts? A procedure found outside privileges in the middle of an operation is a serious risk.
- Is the operative site marked and verified for laterality and multi-level procedures? Confirming the procedure name alone does not rule out a wrong-site error.
How the surveyor verifies this criterion
Sample. The privilege list for all operating surgeons, the operating lists for 10 days, and site-marking records for 15 procedures.
1. Each surgeon has current privileges
Method. Check the privilege list against each surgeon’s file.
Evidence to show. Surgeon privileges and operating list check (SSC-SOP-001).
Pass when. Every operating surgeon has a privilege entry that has not expired.
2. Operating lists are checked
Method. Check each sampled operating list against the privilege list.
Evidence to show. Signed operating list check (SSC-SOP-001).
Pass when. All sampled lists are checked before the first case.
3. Site is marked and verified
Method. Check the records for 15 procedures involving laterality or several levels.
Evidence to show. Surgical site marking record (SRG-SOP-002).
Pass when. The site is marked and verified at the time-out in every sampled procedure.
Good practice. Privileges are reviewed every year, the list check is signed at the start of the day, and the site is marked and checked out loud.
Immediate fail (any one means the criterion is not met). An operation is performed outside the surgeon’s granted privileges.
Partial because. Privileges exist but are not reviewed, or the list is checked verbally but not signed.
Staff, training and documents
Documents
- SSC-SOP-001 Surgeon privileges and operating list check
- SRG-SOP-002 Surgical site marking and patient identification before every operation
E-learning
- Ophthalmology & Day Surgery Safety (Must for surgeons and theatre staff)
7.5Post-Operative Monitoring and Recovery Are SafeHumanitarian settings: MediumTransition and fragile: MustStandard: Must
Patients are monitored after surgery in a recovery area by trained staff, with written discharge criteria. Any deterioration triggers a defined response.
Why it matters. Many post-operative complications, such as bleeding, respiratory depression and sepsis, appear after the patient has left the operating room. A defined recovery and discharge standard catches them in time.
Questions the surveyor asks
- Is there a recovery area with monitoring and trained staff? Recovery is part of the procedure, not an afterthought.
- Are discharge criteria written and applied to every patient? Discharge before the criteria are met is a documented risk.
- Does every patient or escort receive written advice? Verbal advice alone is easy to forget.
How the surveyor verifies this criterion
Sample. Fifteen recovery records and fifteen discharge records from the last 3 months.
1. Recovery monitoring is recorded
Method. Check the observations in each recovery record.
Evidence to show. Recovery monitoring and discharge criteria record (DAY-SOP-001).
Pass when. Observations are recorded at the intervals in DAY-SOP-001 in all sampled records.
2. Discharge criteria are met
Method. Check each discharge record against the criteria.
Evidence to show. Recovery monitoring and discharge criteria (DAY-SOP-001).
Pass when. All sampled discharges meet the criteria, or have a documented senior review.
3. Written advice is given
Method. Check the advice record for each sampled patient.
Evidence to show. Escort and written discharge advice (DAY-POL-002).
Pass when. Written advice is given to every sampled patient or escort.
Good practice. Observations at the defined intervals, and a discharge checklist signed for every patient.
Immediate fail (any one means the criterion is not met). A patient is discharged with no recovery monitoring at all.
Partial because. Recovery is observed but not recorded, or advice is given verbally only.
Staff, training and documents
Documents
- DAY-SOP-001 Recovery monitoring and discharge criteria
- DAY-POL-002 Escort and written discharge advice
- DAY-SOP-004 Pre-procedure checks for day surgery
- DAY-SOP-002 Sedation and anaesthesia level, and response to complications
E-learning
- Ophthalmology & Day Surgery Safety (Must for recovery staff)
7.6Instrument, Swab and Sharps Counts Are CompletedHumanitarian settings: MustTransition and fragile: MustStandard: Must
Instruments, swabs and sharps are counted before the procedure starts, before the wound is closed and before the patient leaves the operating room. Any mismatch is investigated before the team moves on.
Why it matters. Retained surgical items are a serious and preventable harm. A count that is not done, or is done but not recorded, gives no protection.
Questions the surveyor asks
- Are counts done at all three points? Before the procedure, before closure, and before the patient leaves.
- Is there a record that matches the count? A count that is not written down cannot be checked.
- What happens when a count does not match? The team stops and searches before the patient leaves the operating room.
How the surveyor verifies this criterion
Sample. Count records for 20 procedures from the last 3 months, and the incident log for count mismatches.
1. Counts are recorded at each point
Method. Check the count record for each sampled procedure.
Evidence to show. Instrument, swab and sharps count record (to be written).
Pass when. All three counts are recorded in at least 19 of the 20 sampled procedures.
2. Mismatches are investigated
Method. Check the incident log for any count mismatch.
Evidence to show. Incident log entries and their resolution.
Pass when. Every mismatch is recorded and resolved before the patient leaves the operating room.
3. Sharps are disposed of safely
Method. Observe the disposal of sharps in 5 procedures.
Evidence to show. Sharps and clinical waste management (WST-SOP-001).
Pass when. Sharps are placed straight into puncture-proof containers.
Good practice. Counts recorded at all three points, with any mismatch resolved before closure.
Immediate fail (any one means the criterion is not met). A patient leaves the operating room with a count that has not been reconciled.
Partial because. Counts are done but not recorded.
Staff, training and documents
Documents
- WST-SOP-001 Sharps and clinical waste management
- SRG-SOP-001 Surgical safety checklist procedure
E-learning
- Ophthalmology & Day Surgery Safety (Must for theatre staff)
Who is responsible for Standard 7
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 7.1 The Surgical Safety Checklist Is Used | Surgeon (general surgery) Anaesthesiologist |
Operating theatre nurse Theatre technician / scrub practitioner |
| 7.2 Anaesthesia Is Delivered Safely | Anaesthesiologist Nurse anaesthetist |
Biomedical equipment technician |
| 7.3 Surgical Site Infection Is Actively Prevented | Operating theatre nurse Theatre manager |
Sterile services technician Surgeon (general surgery) |
| 7.4 Procedures Are Performed Within Granted Privileges and Marked Correctly | Theatre manager | Surgeon (general surgery) Operating theatre nurse |
| 7.5 Post-Operative Monitoring and Recovery Are Safe | Same-day procedure nurse Anaesthesiologist |
Surgeon (general surgery) |
| 7.6 Instrument, Swab and Sharps Counts Are Completed | Theatre technician / scrub practitioner | Operating theatre nurse Surgeon (general surgery) |
Role details: reporting, supervision and training
Training shown is the general recommendation. Role-specific training is set in the next improvement round.
| Role | Reports to | Supervises | Recommended training |
|---|---|---|---|
| Surgeon (general surgery) | Head of department (per specialty) | Resident physician / house officer | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
| Anaesthesiologist | Head of department (anaesthesia) | Nurse anaesthetist | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
| Nurse anaesthetist | Anaesthesiologist | None | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
| Operating theatre nurse | Theatre manager | None | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
| Theatre technician / scrub practitioner | Theatre manager | None | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
| Theatre manager | Head of surgery | Operating theatre nurse; theatre technicians | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
| Same-day procedure nurse | Head of department (per specialty) | None | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
| Sterile services technician | Sterile services manager | None | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
| Biomedical equipment technician | Biomedical engineer | None | Facility induction; safeguarding adults; Ophthalmology & Day Surgery Safety (general recommendation) |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 7 apply to?
Every facility that performs surgery or invasive procedures, including day surgery and minor procedures under sedation or local anaesthesia. Scale the criteria to the procedures done.
What do the colours mean for this standard?
Red (Must) is required in every setting. Green (Medium) is required, adapted to what a humanitarian or transition setting can realistically do. Yellow (Minimum) is the lowest acceptable level in a humanitarian setting. In standard settings, every criterion is Must.
Must every operation have a completed surgical safety checklist?
Yes. Under 7.1 the checklist is spoken out loud at three pauses, with the whole team taking part. A checklist filled in after the operation does not meet the criterion.
Must a patient be monitored throughout anaesthesia?
Yes. Under 7.2 monitoring is continued through the whole procedure, including emergence, and recorded at least every 5 minutes.
Must every surgical site be marked before the operation?
For procedures involving laterality or several levels, yes. Under 7.4 the site is marked by the operating clinician and verified at the time-out.
Must a discharged patient have written advice?
Yes. Under 7.5 every patient or escort receives written discharge advice, and discharge follows the written criteria.
Do I have to use the documents on this page?
No. The policies, SOPs, forms and registers are drafts to help you. Adapt them to your theatre, write your own, or upload your own. What the assessor checks is that the criterion is met and that you can show how.
What does In process of development mean?
That part of the standard is still being prepared. It may be a document, a course, a reference or a role table. It will be added in a later version.
Guidelines for this standard
9 guidelines are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.
- Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives (World Health Organization)
- Global guidelines for the prevention of surgical site infection, second edition (World Health Organization)
- Implementation manual to support the prevention of surgical site infections at the facility level (World Health Organization)
- Surgical Safety Checklist (Operative Safe Surgery, Kenya) (Operative Safe Surgery, Kenya)
- Safe Surgery Mentor Visit Tool (Operative Safe Surgery, Kenya) (Operative Safe Surgery, Kenya)
- Anaesthesia at the district hospital (World Health Organization)
- Surgical Care at the District Hospital (World Health Organization)
- Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care (World Health Organization)
- WHO Nine Patient Safety Solutions (World Health Organization)
Also relevant to this standard:
- Immediate Post-anaesthesia Recovery 2013 (Association of Anaesthetists of Great Britain and Ireland)
- Guidelines for Day-Case Surgery (Association of Anaesthetists and British Association of Day Surgery)
References
- World Health Organization (2009). Guidelines for Safe Surgery: Safe Surgery Saves Lives. Geneva: WHO.
- World Health Organization (2008). Safe Surgery Saves Lives: Global Patient Safety Challenge 2008-2009. Geneva: WHO. (Source of the WHO Surgical Safety Checklist.)
- World Health Organization (2016). Global guidelines for the prevention of surgical site infection. Geneva: WHO.
- World Health Organization (2021). Global Patient Safety Action Plan 2021-2030. Geneva: WHO.
- World Health Organization (2003). Surgical care at the district hospital. Geneva: WHO.