Standard operating procedure

Surgical Safety Checklist & Procedure Verification Procedure

The step-by-step procedure for verifying the right patient, right site and right procedure, and for completing a WHO-style Surgical Safety Checklist across Sign In, Time Out and Sign Out for every invasive procedure or operation.

For Private Healthcare ClinicRef BS-PH-SOP-002See a sample (PDF) →
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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Equipment and materials
  • 6. Procedure
  • 7. Documentation
  • 8. Records and audit
  • 9. Related documents
  • 10. Review and version control
  • 11. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (Safe care and treatment)
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17 (Good governance)
  • World Health Organization Surgical Safety Checklist (2009) and Implementation Manual
  • National Safety Standards for Invasive Procedures (NatSSIPs 2) (2023)
  • Mental Capacity Act 2005
  • General Medical Council, Decision making and consent (2020)

Who it applies to

All operators, anaesthetists and sedationists, scrub and circulating practitioners, recovery staff, healthcare assistants and any locum, bank or agency staff at [Organisation Name] who plan, consent, anaesthetise, perform, assist with or recover patients undergoing an invasive procedure or surgery.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Anaesthesia
Medication used to remove pain or sensation, ranging from numbing one area to making the patient fully unconscious for surgery.
Anaesthetist
A doctor trained to give anaesthesia and monitor the patient's vital functions during a procedure.
Antibiotic prophylaxis
Giving an antibiotic before or during a procedure to reduce the risk of infection.
Anticoagulation
Medicines that thin the blood and slow clotting, which may need to be checked or paused before a procedure.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Circulating practitioner
A theatre team member who works outside the sterile field, fetching equipment and supporting the procedure.
Commissioner
An organisation that arranges and pays for healthcare services on behalf of patients.
Comorbidity
An additional health condition a patient has alongside the one being treated.
Contemporaneously
Written down at the time the action happens, rather than from memory afterwards.
Cross-match
A blood test that checks donor blood is compatible with the patient's before a transfusion.
Decision making and consent (General Medical Council, 2020)
Professional guidance from the doctors' regulator on how to involve patients in decisions and obtain valid consent.
Endoscopy
Examining inside the body using a thin tube with a camera, such as during a gastroscopy or colonoscopy.
Fasting status
Whether the patient has gone without food or drink for the required period before anaesthesia or sedation.
General Medical Council (GMC)
The body that registers doctors in the United Kingdom and sets the standards they must meet.
Good governance
Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, requiring providers to run safe, well-managed systems and keep accurate records.
Group-and-save
A blood test that records the patient's blood group so compatible blood can be provided quickly if needed.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards that providers of regulated care must meet, enforced by the Care Quality Commission.
Implant
A device or material placed inside the body during a procedure, such as a joint replacement, mesh or breast implant.
Indelible pen
A permanent marker whose mark stays visible after skin cleaning and draping, used to mark the surgical site.
Induction of anaesthesia
The point at which a patient is given anaesthetic to start the process of being made unconscious.
Interventional procedure
A treatment that enters the body through a small opening or under imaging guidance rather than open surgery.
Invasive procedure
Any procedure that breaks the skin or a body lining, enters a body cavity, or places something inside the body.
Laterality
Which side of the body (left or right) a procedure is to be carried out on.
Local Safety Standards for Invasive Procedures (LocSSIPs)
A clinic's own written safety steps for each specific procedure, developed from the national standards and tailored to its services.
Mental Capacity Act 2005
The law that protects and supports people who may be unable to make particular decisions for themselves.
Mucous membrane
The moist lining of body openings such as the mouth, nose, gut or genitals.
National Safety Standards for Invasive Procedures (NatSSIPs 2)
National safety standards setting out the step-by-step and organisational checks that prevent avoidable harm during invasive procedures.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Never Event
A serious, largely preventable patient safety incident, such as wrong-site surgery, that should not happen if national guidance is followed.
Operator
The surgeon or clinician who actually performs the procedure on the patient.
Prophylaxis
Treatment given to prevent a problem from occurring, rather than to treat one that already exists.
Pulse oximeter
A small device, usually clipped to a finger, that measures the oxygen level in the patient's blood.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Regulation 12 (Safe care and treatment)
The part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requiring care to be provided safely, including avoiding preventable harm.
Scrub practitioner
A theatre team member working within the sterile field who manages instruments and counts swabs, needles and sharps.
Sedation
Medication that relaxes a patient and reduces awareness during a procedure without making them fully unconscious.
Sharps
Needles, blades and other items that can cut or puncture the skin.
Sign In
The first phase of the Surgical Safety Checklist, completed before anaesthesia or before the procedure starts.
Sign Out
The final phase of the Surgical Safety Checklist, completed before the patient leaves the procedure room.
Site marking
Marking the correct operative site on the body with a permanent pen before the procedure begins.
Standard Operating Procedure (SOP)
A written, step-by-step instruction setting out how a particular task must be carried out consistently and safely.
Stop the line
The authority for any team member to halt a procedure immediately if they have a safety concern, without fear of blame.
Surgical Safety Checklist
A structured list of safety checks, completed in three phases, to confirm the right patient, site and procedure and prevent avoidable harm.
Time Out
The middle phase of the Surgical Safety Checklist, a team pause immediately before the procedure starts.
Venous thromboembolism (VTE)
A blood clot forming in a vein, including deep vein thrombosis and pulmonary embolism, which preventive measures aim to avoid.
World Health Organization (WHO)
The United Nations agency for international public health, which publishes the original Surgical Safety Checklist.

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