These safety checks are to be completed before induction of anaesthesia in order to confirm the safety of proceeding. It requires the presence of the anaesthetist and nursing personnel at the very least.
The checklist coordinator may complete this section all at once or sequentially, depending on the flow of preparation for anaesthesia. The details for each of the safety steps are as follows:
Has the patient confirmed his/her identity, site, procedure and consent?
The Checklist coordinator verbally confirms the patient's identity, the type of procedure planned, the site of surgery and that consent for surgery has been given. While it may seem repetitive, this step is essential for ensuring that the team does not operate on the wrong patient or site or perform the wrong procedure. When confirmation by the patient is impossible, such as in the case of children or incapacitated patients, a guardian or family member can assume this role. If a guardian or family member is not available or if this step is skipped, such as in an emergency, the team should understand why and all be in agreement prior to proceeding.
Is the site marked?
The Checklist coordinator should confirm that the surgeon performing the operation has marked the site of surgery (usually with a permanent felt-tip marker) in cases involving laterality (a left or right distinction) or multiple structures or levels (e.g. a particular finger, toe, skin lesion, vertebra). Site-marking for midline structures (e.g. thyroid) or single structures (e.g. spleen) should follow local practice. Consistent site marking in all cases, however, can provide a backup check confirming the correct site and procedure.
Is the anaesthesia machine and medication check complete?
The Checklist coordinator completes this next step by asking the anaesthetist to verify completion of an anaesthesia safety check, understood to be a formal inspection of the anaesthetic equipment, breathing circuit, medications and patient's anaesthetic risk before each case. A helpful mnemonic is that, in addition to confirming that the patient is fit for surgery, the anaesthesia team should complete the ABCDEs – an examination of the Airway equipment, Breathing system (including oxygen and inhalational agents), suCtion, Drugs and Devices and Emergency medications, equipment and assistance to confirm their availability and functioning.
Is the pulse oximeter on the patient and functioning?
The Checklist coordinator confirms that a pulse oximeter has been placed on the patient and is functioning correctly before induction of anaesthesia. Ideally the pulse oximetry reading should be visible to the operating team. An audible system should be used to alert the team to the patient's pulse rate and oxygen saturation. Pulse oximetry has been highly recommended as a necessary component of safe anaesthesia care by WHO. If no functioning pulse oximeter is available, the surgeon and anaesthetist must evaluate the acuity of the patient's condition and consider postponing surgery until appropriate steps are taken to secure one. In urgent circumstances to save life or limb this requirement may be waived, but in such circumstances the team should be in agreement about the necessity to proceed with the operation.
Does the patient have a known allergy?
The Checklist coordinator should direct this and the next two questions to the anaesthetist. First, the coordinator should ask whether the patient has a known allergy and, if so, what it is. If the coordinator knows of an allergy that the anaesthetist is not aware of, this information should be communicated.
Does the patient have a difficult airway/aspiration risk?
The Checklist coordinator should verbally confirm that the anaesthesia team has objectively assessed whether the patient has a difficult airway. There are a number of ways to grade the airway (such as the Mallampati score, thyromental distance, or Bellhouse-Doré score). An objective evaluation of the airway using a valid method is more important than the choice of method itself. Death from airway loss during anaesthesia is still a common disaster globally but is preventable with appropriate planning. If the airway evaluation indicates a high risk for a difficult airway (such as a Mallampati score of 3 or 4), the anaesthesia team must prepare against an airway disaster. This will include, at a minimum, adjusting the approach to anaesthesia (for example, using a regional anaesthetic, if possible) and having emergency equipment accessible. A capable assistant—whether a second anaesthetist, the surgeon, or a nursing team member—should be physically present to help with induction of anaesthesia.
The risk of aspiration should also be evaluated as part of the airway assessment. If the patient has symptomatic active reflux or a full stomach, the anaesthetist must prepare for the possibility of aspiration. The risk can be reduced by modifying the anaesthesia plan, for example using rapid induction techniques and enlisting the help of an assistant to provide cricoid pressure during induction. For a patient recognized as having a difficult airway or being at risk for aspiration, induction of anaesthesia should begin only when the anaesthetist confirms that he or she has adequate equipment and assistance present at the bedside.
Does the patient have a risk of >500 ml blood loss (7 ml/kg in children)?
In this safety step, the Checklist coordinator asks the anaesthesia team whether the patient risks losing more than half a litre of blood during surgery in order to ensure recognition of and preparation for this critical event. Large volume blood loss is among the most common and important dangers for surgical patients, with risk of hypovolaemic shock escalating when blood loss exceeds 500 ml (7 ml/kg in children). Adequate preparation and resuscitation may mitigate the consequences considerably.
Surgeons may not consistently communicate the risk of blood loss to anaesthesia and nursing staff. Therefore, if the anaesthetist does not know what the risk of major blood loss is for the case, he or she should discuss the risk with the surgeon before the operation begins. If there is a significant risk of a greater than 500 ml blood loss, it is highly recommended that at least two large bore intravenous lines or a central venous catheter be placed prior to skin incision. In addition, the team should confirm the availability of fluids or blood for resuscitation. (Note that the expected blood loss will be reviewed again by the surgeon before skin incision. This will provide a second safety check for the anaesthetist and nursing staff.)
At this point this phase is completed and the team may proceed with anaesthetic induction.
