Orthopedic Surgical Safety Checklist Form
Patient & Procedure Information
Patient Name
MRN / ID
Date of Surgery
Surgeon
Procedure
Surgical Site / Side
Anesthesia
Before Induction of Anesthesia
Patient identity confirmed
Surgical site marked
Consent obtained
Allergies checked
Anesthesia safety check completed
Difficult airway/aspiration risk?
Before Skin Incision
Team introductions (name/role)
Confirm patient and procedure
Prophylactic antibiotics given
Imaging displayed/available
Equipment/implants needed available
Before Patient Leaves Operating Room
Procedure & specimen confirmed
Count of instruments & sponges complete
Equipment concerns addressed
Post-op plan discussed
Team Leader Name
Signature
Date/Time