Surgical Time-Out Checklist Form
Complete this checklist before beginning any surgical or procedural intervention to ensure patient safety and team readiness.
Patient identification confirmed?
*
Yes
No
Not applicable
Procedure to be performed verified with consent and documentation?
*
Yes
No
Not applicable
Surgical/procedure site marked and confirmed?
*
Yes
No
Not applicable
Patient allergies checked and documented?
*
No known allergies
Allergies present (see chart)
Unknown
Team members have introduced themselves by name and role?
*
Yes
No
Anticipated critical events discussed?
*
Yes
No
Not applicable
Equipment and implants confirmed as available and functioning?
*
Yes
No
Not applicable
Imaging (if required) displayed and verified?
*
Yes
No
Not required
Antibiotic prophylaxis administered (if required)?
*
Yes
No
Not required
Patient positioning and pressure points checked?
*
Yes
No
Not applicable
Other safety concerns or comments
Submit Checklist
Should be Empty: