Standards › Standard 2 › Forms
Form · SRG-FRM-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2.1
Purpose
The WHO surgical safety checklist for one procedure, completed aloud at sign-in, time-out and sign-out.
How to complete
- Complete at each of the three pauses.
- Record each item as read aloud.
- Sign by the surgeon, anaesthetist and nurse.
Checks
| Check | Entry |
|---|---|
| Sign in: identity, site marked, allergies, equipment and anaesthesia safety checked | Yes |
| Time-out: patient, procedure, site, antibiotics, critical events and imaging confirmed aloud | Yes |
| Sign out: instrument, swab and sharps counts read aloud | Yes |
| Specimens labelled and read back | Yes or N/A |
| Surgeon, anaesthetist and nurse signatures | Yes |
Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Surgical Safety Checklist (2009). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)