Sample policy · Ophthalmology

Surgical safety checklist policy for ophthalmic day surgery (ophthalmology)

1. Purpose

Most eye surgery is day surgery under local anaesthetic, with a high turnover of similar cases. That pattern is efficient, but it is exactly where a routine slip can cause harm. A surgical safety checklist makes the whole team pause and confirm the key facts together before each case. This policy sets out how the Service runs that checklist for ophthalmic day surgery, alongside the eye and lens checks in the correct patient, correct eye, correct lens policy.

The Service must verify this policy against the WHO Surgical Safety Checklist, the National Safety Standards for Invasive Procedures and Royal College of Ophthalmologists guidance before adoption.

2. Sources to verify before adoption

3. Scope

This policy applies to:

4. The team and the genuine pause

The checklist works only if the whole team stops and takes part. The Service expects:

5. The three phases of the checklist

The checklist is adapted from the WHO Surgical Safety Checklist for ophthalmic surgery and run at three points:

  1. Sign in (before the patient enters the operating area): identity confirmed; operative eye confirmed and marked (per the correct patient, correct eye, correct lens policy); consent confirmed; procedure and lens confirmed; allergies checked; anticoagulant and antiplatelet medicines reviewed; anaesthetic plan and any known difficulty confirmed; the required equipment and the correct intraocular lens confirmed as present.
  2. Time out (before the procedure starts): the team pauses; each member is known by name and role; identity, eye, procedure, consent and lens are confirmed against the record; the marked eye is confirmed as the eye prepared and draped; any anticipated problem is shared.
  3. Sign out (before the patient leaves the operating area): the procedure performed and the lens implanted are recorded (with power, model and serial or lot number); instrument, swab and sharps accounts are correct; any complication or change from plan is recorded; the recovery and discharge plan, including follow-up and who to contact, is confirmed.

6. Local anaesthetic and sedation safety

Because most cases use local anaesthetic, sometimes with sedation, the Service:

7. Recovery and discharge

Day surgery is safe only if discharge is safe. Before the patient leaves the Service confirms:

8. When the checklist fails or a complication occurs

If a step is missed, a concern is overruled, or a complication occurs, the event is logged the same day as a patient-safety incident and runs through to a recorded outcome with completed actions. A Never Event (wrong eye, wrong implant, retained item) opens the duty of candour and the serious-incident process.

9. Training

Everyone in the theatre and recovery team is trained in the checklist, their role in it, and stop-the-line authority, at induction and on a refresher cadence the Service sets. The Service records completion and the next refresher date.

10. Audit cadence

The Service checks, on a stated cadence, that:

The Registered Manager and the lead surgeon review the results and record the improvement actions that follow.

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Last reviewed 5 June 2026