Surgical Site Verification Checklist (Time Out)
This surgical site verification checklist ensures compliance with The Joint Commission Universal Protocol to prevent wrong site, wrong procedure, and wrong person surgery.
- Industry: Healthcare
- Frequency: Per Surgical Procedure
- Estimated Time: 5-10 minutes
- Role: Surgeon / Circulating Nurse / Anesthesiologist
- Total Items: 32
- Compliance: TJC Universal Protocol, WHO Surgical Safety Checklist, CMS CoP, AORN Guidelines
Pre-Procedure Verification
Initial verification before procedure
- Patient identity confirmed with 2 identifiers
- Surgical consent signed and complete
- Procedure matches consent form
- Site matches consent and schedule
- Required imaging/labs available
- Required implants/special equipment available
Surgical Site Marking
Site marking verification
- Surgical site marked by operating surgeon
- Site marking visible after draping
- Site marking location
- If bilateral - both sites marked appropriately
- Patient involved in site marking (if possible)
Time Out (Immediately Before Incision)
Final verification before procedure begins
- All team members present and attentive
- Correct patient confirmed
- Correct procedure confirmed
- Correct site/side confirmed
- Patient positioning correct
- Prophylactic antibiotic given (within 60 min)
- Allergies announced
- VTE prophylaxis addressed
Team Communication
Critical information sharing
- Surgeon: Critical steps, case duration, blood loss anticipated
- Anesthesia: Patient-specific concerns addressed
- Nursing: Sterility, equipment, counts confirmed
- Fire risk assessment completed
Team Sign-Off
Documentation of time out completion
- Time out completed before incision
- Time out performed at (time)
- Surgeon Signature
- Circulating RN Signature
- Anesthesia Provider Signature
Infection Prevention & Control
Infection control per CDC/Joint Commission
- Hand hygiene compliance observed?
- Isolation precautions followed correctly?
- Sharps containers not overfilled?
- Appropriate PPE available and used?
Related Healthcare Checklists
- WHO Surgical Safety Checklist
- WHO Surgical Safety Checklist
- Patient Hand-Off Communication Checklist (SBAR)
- Patient Identification Verification Checklist
- Medication Reconciliation at Admission Checklist
- HIPAA Privacy Compliance Audit Checklist
Related Surgical Safety Checklists
Why Use This Surgical Site Verification Checklist (Time Out)?
This surgical site verification checklist (time out) helps healthcare teams maintain compliance and operational excellence. Designed for surgeon / circulating nurse / anesthesiologist professionals, this checklist covers 32 critical inspection points across 6 sections. Recommended frequency: per surgical procedure.
Ensures compliance with TJC Universal Protocol, WHO Surgical Safety Checklist, CMS CoP, AORN Guidelines. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Surgical Site Verification Checklist (Time Out) cover?
This checklist covers 32 inspection items across 6 sections: Pre-Procedure Verification, Surgical Site Marking, Time Out (Immediately Before Incision), Team Communication, Team Sign-Off, Infection Prevention & Control. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed per surgical procedure. Each completion takes approximately 5-10 minutes.
Who should use this Surgical Site Verification Checklist (Time Out)?
This checklist is designed for Surgeon / Circulating Nurse / Anesthesiologist professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.