Nursing MediumThree pauses: remember the timing
The checklist supports shared safety checks and communication. It supplements clinical judgement and local protocols; completing a form alone does not make surgery safe.
| Phase | When? | Main focus |
|---|---|---|
| Sign in | Before induction of anaesthesia | Confirm identity and readiness for anaesthesia. |
| Time out | Immediately before skin incision | The operating team pauses and agrees on the surgical plan. |
| Sign out | Before the patient leaves the operating room | Check completion details and communicate recovery needs. |
Exam clue: “Entire team confirms patient, site and procedure before incision” = Time out. The timing matters because identity is checked more than once.
1. Sign in: ready for anaesthesia?
At least the nurse and anaesthesia professional take part. Involve the patient where possible.
- Verify the patient, planned procedure, site and consent; confirm site marking when applicable.
- Check anaesthesia equipment and medicines, and a working pulse oximeter.
- Review allergies, airway/aspiration concerns and the plan for anticipated bleeding.
Number to remember: the WHO 2009 checklist flags anticipated blood loss over 500 mL in adults or 7 mL/kg in children. This is a planning prompt, not a transfusion threshold.
2. Time out: pause before incision
Surgeon, anaesthesia professional and nursing team participate actively. Confirm names/roles, patient, site and procedure aloud.
- Surgeon: explain critical steps, expected duration and bleeding concerns.
- Anaesthesia professional: share patient-specific risks.
- Nursing team: confirm sterility indicators, equipment readiness and concerns.
- Check required imaging is available and displayed as appropriate.
- Confirm indicated antibiotic prophylaxis: the WHO checklist asks about administration within the preceding 60 minutes.
Antibiotic timing: use the prescribed agent’s infusion requirements and local policy. The checklist prompt is not a universal rule for every drug or every procedure.
3. Sign out: safe completion and handover
Complete this before the patient leaves OT and while relevant team members are available; it can take place during wound closure.
- Confirm what procedure was actually performed.
- Confirm instrument, swab/sponge and needle counts; resolve discrepancies using local policy.
- Read specimen labels aloud, including patient identity, and verify specimen details.
- Identify equipment faults needing action.
- Agree on recovery concerns and the postoperative management plan.
Example: checking counts, specimen labels and recovery concerns before transfer is Sign out.
The nurse’s role
A designated coordinator leads the checks—often the circulating nurse, but not necessarily. The scrub nurse contributes sterility, instrument/count and equipment information with the circulating nurse. Safety remains the whole team’s responsibility.
Common exam confusions
- “Sign in” means before induction, not simply arrival at the OT door.
- “Time out” is a shared pause, not the nurse checking silently.
- “Sign out” happens before OT exit, not later on the ward.
- Emergency care may require adaptation and communication; do not assume checks can simply be ignored.
10 original MCQs with rationales
Choose an option, then open the explanation. These are original revision questions, not claimed PGI/PGIMER previous-year questions.
Q1. The whole operating team confirms the patient, site and procedure immediately before laparoscopic incision. Which phase is this?
- Sign in
- Sign out
- Time out
- Recovery handover
Show answer & rationale
Answer: C. Time out
Time out is the team pause immediately before incision. Identity confirmation alone is not enough to distinguish phases; use the timing.
Q2. When should Sign in be completed?
- Before induction of anaesthesia
- After the first incision
- After transfer to recovery
- Only after the operation
Show answer & rationale
Answer: A. Before induction of anaesthesia
Sign in checks readiness before anaesthesia is induced.
Q3. Which finding belongs to the Sign in safety review?
- Final specimen label
- Completed operative procedure
- Postoperative ward allocation only
- Known allergy and airway risk
Show answer & rationale
Answer: D. Known allergy and airway risk
Allergy and airway/aspiration concerns must be identified before induction so appropriate preparations can be made.
Q4. During Time out, what should the nursing team specifically confirm?
- The discharge date
- Sterility indicators and equipment concerns
- That all postoperative medicines have been given
- That patient identity never needs rechecking
Show answer & rationale
Answer: B. Sterility indicators and equipment concerns
The nursing contribution includes sterility and equipment readiness. Other team members share their own operative concerns.
Q5. The WHO 2009 Time out prompt asks whether indicated antibiotic prophylaxis was given within which preceding interval?
- 6 hours
- 24 hours
- 60 minutes
- After wound closure
Show answer & rationale
Answer: C. 60 minutes
The checklist uses a 60-minute prompt before incision. Drug-specific infusion needs and local prophylaxis policy still apply.
Q6. Counts, specimen labels and recovery concerns are reviewed before the patient leaves OT. Which phase is this?
- Sign out
- Sign in
- Time out
- Pre-admission assessment
Show answer & rationale
Answer: A. Sign out
Sign out checks completion and supports transfer of relevant postoperative information.
Q7. Which is the best way to verify a surgical specimen label during Sign out?
- Use the theatre number alone
- Leave the label blank until the ward round
- Assume it matches because the container is nearby
- Read the label aloud and confirm patient and specimen details
Show answer & rationale
Answer: D. Read the label aloud and confirm patient and specimen details
Verbal verification helps detect identification errors before the specimen leaves the team’s control.
Q8. Who commonly coordinates the checklist?
- Only the hospital administrator
- A designated team member, often the circulating nurse
- Only the patient
- Only the scrub nurse in every case
Show answer & rationale
Answer: B. A designated team member, often the circulating nurse
A designated coordinator leads the process. A circulating nurse often does this, but the role is not restricted to one profession.
Q9. Before incision, the stated operative side does not match the documented plan. What should the nurse do?
- Continue and clarify after surgery
- Tick the item because the team is busy
- Speak up, pause progression and resolve the discrepancy with the team
- Change the record without verification
Show answer & rationale
Answer: C. Speak up, pause progression and resolve the discrepancy with the team
A discrepancy requires verification and escalation. An unchecked assumption must not be recorded as a completed safety check.
Q10. Which statement best describes effective checklist use?
- It requires active verbal checks and team participation
- It replaces clinical judgement
- It guarantees no complications
- It is completed from memory after the patient leaves
Show answer & rationale
Answer: A. It requires active verbal checks and team participation
The checklist is a communication tool used at the relevant moments. It complements judgement and cannot guarantee an uncomplicated outcome.
Sources & editorial note
- WHO Surgical Safety Checklist: Implementation Manual (2009)
- WHO guidance: before induction of anaesthesia
- WHO guidance: before skin incision
- WHO guidance: before the patient leaves OT
Educational summary and original questions by Nursing Medium, based on the listed sources. Not an official WHO checklist or a substitute for supervised training and institutional policy. Independent clinical review has not been claimed. Sources checked 17 October 2026.