Checklist Compliance Audit Form
Ten observed cases a month. Observation, not signatures
What it is
Monthly observation audit: for ten cases, whether each pause was performed, read aloud, with all team members attentive, and whether every item was answered. Produces a compliance percentage the theatre board can act on.
Where to use it
Quality lead; completed by an observer in theatre, not by the operating team. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement. Evidence for: Hospital Standard 4 — surgical safety; Governance — measurement and improvement.
Translate and adapt
English master edition. Georgian and other translations are added as they are clinically reviewed. Any facility may translate, add its logo and adapt wording to local practice — keeping the ASF block, the source attribution and the licence line on the sheet. Clinical thresholds and drug doses must be confirmed against national protocols before use.
The same code is printed on the tool itself. Scan it in any facility to reach this page.
Surgical Safety Checklist
Time-Out Briefing Card
Surgical Safety Checklist — Implementation Guide
Have We Done the Time Out?
Print to share.
