Veterinary Surgical Safety Checklist Template

Veterinary Surgical Safety Checklist

Based on AAHA Anesthesia and Monitoring Guidelines (2020) and adapted from the WHO Surgical Safety Checklist

This checklist is designed to be completed collaboratively by the surgical team (surgeon, anesthetist, and surgical assistant) at three critical phases: before induction, before incision, and before the patient leaves the surgical suite.

Phase 1: Sign-In (Before Anesthesia Induction)

Patient Identification

[ ] Patient identity confirmed (name, species, breed, age, weight)
[ ] Client identity and consent form signed
[ ] Correct surgical site confirmed and marked (if applicable)
[ ] Correct procedure confirmed with surgical consent

Pre-Anesthetic Assessment

[ ] ASA physical status classification assigned: ___
[ ] Pre-anesthetic bloodwork reviewed (date performed: ___)
[ ] Known allergies or adverse drug reactions documented: ___
[ ] NPO status confirmed (last meal: ___)
[ ] Current medications reviewed and documented

Anesthesia Preparation

[ ] Anesthetic protocol documented and appropriate for ASA status
[ ] IV catheter placed and patent
[ ] Emergency drugs calculated and drawn up:
Atropine: ___ mg (___ mL)
Epinephrine: ___ mg (___ mL)
Doxapram: ___ mg (___ mL)
[ ] Endotracheal tube size selected: ___
[ ] Backup ET tube available: ___
[ ] Monitoring equipment functional:
[ ] Pulse oximeter
[ ] Capnograph
[ ] ECG
[ ] Blood pressure monitor
[ ] Temperature probe
[ ] Fluid therapy calculated: ___ mL/hr of ___

Phase 2: Time-Out (Before Incision)

All team members pause and confirm:

Team Introduction

[ ] All team members have introduced themselves and their roles

Patient Confirmation

[ ] Correct patient confirmed
[ ] Correct procedure confirmed
[ ] Correct surgical site confirmed

Surgeon's Statement

[ ] Expected procedure duration: ___ minutes
[ ] Anticipated blood loss risk: Low / Moderate / High
[ ] Any patient-specific concerns: ___

Anesthetist's Statement

[ ] Anesthetic depth adequate
[ ] Vital signs stable (HR: ___ RR: ___ SpO2: ___ BP: ___ Temp: ___)
[ ] Any anesthetic concerns: ___

Sterility Confirmation

[ ] Surgical site clipped and prepped
[ ] Sterile drapes applied
[ ] Instrument count completed: ___ instruments
[ ] Sterility of instruments confirmed
[ ] Implants/prosthetics verified (if applicable): ___

Antibiotic Prophylaxis

[ ] Prophylactic antibiotics administered: ___ at ___
[ ] Not indicated (reason: ___)

Phase 3: Sign-Out (Before Patient Leaves Surgery)

Procedure Completion

[ ] Procedure name confirmed as performed: ___
[ ] Surgeon satisfied with procedure outcome
[ ] Any intraoperative complications documented: ___

Instrument and Material Count

[ ] Instrument count correct: ___ / ___
[ ] Sponge/gauze count correct: ___ / ___
[ ] Needle count correct: ___ / ___
[ ] No retained surgical items suspected

Specimen Management

[ ] Specimens labeled and logged: ___
[ ] Histopathology submission form completed
[ ] No specimens collected (N/A)

Recovery Plan

[ ] Post-operative analgesic plan documented
[ ] Recovery monitoring assignments confirmed
[ ] Extubation criteria defined
[ ] Client notification plan confirmed

Post-Operative Orders

[ ] Pain management protocol: ___
[ ] Fluid therapy continuation: Yes / No
[ ] Activity restrictions documented
[ ] Recheck appointment scheduled: ___
[ ] Discharge instructions prepared

How to Use This Checklist

Print and laminate — keep copies in the surgical prep area
Assign a checklist leader — typically the anesthetist or surgical nurse
Complete verbally — each item is read aloud and confirmed by the responsible team member
Document completion — note checklist completion in the surgical record
Review and adapt — modify this template to match your practice's specific procedures and equipment

Sources

AAHA. (2020). Anesthesia and Monitoring Guidelines for Dogs and Cats.
WHO. (2009). WHO Surgical Safety Checklist (adapted for veterinary use).
ACVAA. (2023). Monitoring Recommendations for Anesthetized Veterinary Patients.

PetChart's task management and clinical checklists let you digitize this checklist and integrate it directly into your surgical workflow. Start your free trial.

Veterinary Surgical Safety Checklist Template