Standards › Standard 2 › Policies
Policy · SRG-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2.1
At a glance
- Every procedure has a surgical safety checklist, completed aloud by the team.
- The checklist has three pauses: sign-in, time-out before incision, and sign-out.
- Patient, procedure and body site are verified at the time-out.
- The checklist is completed before the procedure, not written up afterwards.
- Stop and get help straight away if: a procedure starts with no time-out, or the checklist is completed after the patient has left the theatre.
1. Purpose
To make sure the team confirms the right patient, the right procedure and the right site together, at each pause (2.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
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.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Theatre manager | Owns the checklist and audits it | Management |
| Surgeon | Leads the time-out | Surgeon |
| Anaesthetist and nurse | Read and confirm each item aloud | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Sign in.
- Before induction, the anaesthetist and nurse confirm identity, site marking, allergies and equipment aloud (SRG-FRM-001).
Key point: Before anaesthesia, not after.
Step 2. Time-out.
- Before incision, the whole team stops and says aloud: patient, procedure, site, antibiotics, critical events and imaging.
- Nobody starts until everyone has spoken.
Key point: The team pause is the check.
Step 3. Sign out.
- Before the patient leaves the theatre, the nurse reads out the instruments and swabs count, the specimens and any equipment problems.
Key point: Counts are read aloud.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Procedures with checklist completed in all three pauses | 100% | Monthly | Theatre manager | Escalate to chief executive |
| Procedures with time-out before incision | 100% | Monthly | Theatre manager | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| SRG-SOP-001 | Surgical safety checklist procedure | Procedure |
| SRG-FRM-001 | Surgical safety checklist record | Record |
| ID-FRM-001 | Patient identification check log | Identity check |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Based on the WHO Surgical Safety Checklist (2009). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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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)