The checklist
13 sections of verified safety.
The full 3Greens checklist organizes every surgical safety step into 13 categories. Every category, every step, every surgery — nothing depends on memory.
1. Preop Area Checklist (9 items)
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- ✓Chlorhexadine (CHG) wipe to surgical site
- ✓Review TXA contraindication: clotting, stroke
- ✓Allergies, and Latex Allergy?
- ✓Patient and family questions answered
- ✓No skin infections. No Respiratory symptoms
- ✓Nasal decolonization with 10% iodine swabs
- ✓Surgical and post-surgical plan reviewed with patient and family
- ✓Family member mobile number and name recorded
- ✓EHR: h+p update, admit order, orders
2. Flight Brief: Initial OR Visit (22 items)
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- ✓Visit OR and greet staff, getting all names including guests on the white board
- ✓Any guests or new team members today? Special welcome and additional training
- ✓Set room temp 69F / 21C
- ✓Review surgical plan with staff and positioning
- ✓Welcome and remind Anesthesia/CRNA: TXA; Sufenta instead of Remi; Avoid Ketamine
- ✓Fluid Warmer in Room
- ✓Both lightboxes in room
- ✓Lateral X-Ray holder and lead shield in room
- ✓Confirm Cell saver ordered and machine in room
- ✓Confirm Imaging ordered including Large Field C-Arm Fluoroscopy
- ✓Instrument layout photograph available for new staff
- ✓Specials for Today — all equipment available?
- ✓Give Circulator Saline: Betadine concentration 3:1
- ✓Check Jackson Table Pin Position and test up/down/tberg/locking
- ✓Thigh foam pad and 3 pillows at foot to keep knee caps free
- ✓Stool under table for X-Ray
- ✓Put on under-body warmer on Jackson Table. Connect and turn on warmers x2
- ✓Sutures for the Field: VLock 3-0 x2, Quill or StrataFix #2 double-ended
- ✓Bone Graft ordered
- ✓Dural repair supplies in room: 6-0 Proline, Duraseal, Surgicel
- ✓Diamond and metal cutting bur available in room
- ✓Prep table setup: Sterile 4x4s, Alcohol, Chloroprep x2, Sterile Pen, Integuseal
- ✓Answer any questions from OR team. Thank You for Help.
3. Before Turning (11 items)
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- ✓In OR Time — Wheels in
- ✓Tape up all preop imaging on the wall and/or pull up digitally on monitor
- ✓Put Warm Blankets On Patient Immediately
- ✓Double-Check Jackson Table pad positions for patient size
- ✓Foley placed with good urine flow
- ✓Pneumatic boots applied (non-pediatric) and turned on
- ✓Evoked Potential Wire Placement Done
- ✓Endo-Tracheal tube taped securely and tube depth confirmed by 2 team members
- ✓Bite block x2 between molars with test jaw close confirmed by 2 team members
- ✓Stretcher and Jackson Table heights set correctly and tables locked
- ✓Ensure all lines, foley, wires are free, foley threaded through under-warmer
- ✓NM Tech: Identify Needle Locations for Staff Safety and wrists/hands wrapped with towel
4. Positioning (19 items)
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- ✓Patient gently turned to prone position with surgeon’s help, arms positioned
- ✓Face carefully positioned in Prone View with eyes protected and visible without pressure — 2 team member cross-check
- ✓ET Tube and bite blocks secure and proper depth, tight connections — 2 team member cross-check
- ✓Lips and Ears without pressure — 2 team member cross-check
- ✓Chest roll is away from the brachial plexus and airway — 2 team members
- ✓Neck in neutral position — 2 team members
- ✓For women, adjust breasts to minimize pressure on nipples
- ✓New warm blankets on entire patient
- ✓Turn on warmers on high
- ✓Elbows and shoulders at 90 degrees, no pressure on ulnar nerve
- ✓Arm boards out of way for surgeon, all connectors tight
- ✓Pneumatic boots on, plugged in and turned on
- ✓Add additional foam under iliac wings if needed for thin patients
- ✓Pelvis level, thighs on pads, knees no pressure, legs on pillows with knees flexed, strap on
- ✓Under Patient: Abdomen hanging free without pressure
- ✓Under Patient: Genitals free of pressure, not lying on foley valve
- ✓Under Patient: Tape/Velcro up Foley and NM wires to be out of way of C-Arm
- ✓Reverse Trendelenberg approximately 4 degrees — eye/airway protection
- ✓Check that all IV and Arterial connectors are all double-checked tight
5. Prep and Drape (15 items)
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- ✓Set Tracker/Timers for OR Time, Surgical Time, q30m anesthesia and leg check, 90m family call, 2h glove change
- ✓If needed, Shoulders/Buttock taped to prevent creasing
- ✓Upper and Lower Warm blankets applied
- ✓4×4 sterile sponge alcohol wipe down entire back, avoiding pooling for fire risk avoidance
- ✓Surgical lights lined up over the surgical field, kissing, high enough to avoid head bump
- ✓Stick-on plastic 1010 drapes at least 3 inches from expected incision ends, 5 or more inches each side
- ✓Tape top 1010 up to blankets to prevent contamination
- ✓Chlorhexadine Dry x3 min and no pooling on field or on sheets below — fire risk
- ✓Skin incision and cross-hatches marked with sterile marker
- ✓Large Sticky Drape, Splits, and edges sealed with sticky drapes
- ✓Red banner or Tape across main OR door — infection prevention
- ✓Confirm patient stretcher location outside door with room label — emergent flip
- ✓Family phone number and name on white board
- ✓Trip Hazard Removal and Check: Tape down or remove all wires/tubes on floor
- ✓Set Bovie 50 coag, 70 cut, Bip 70, TPS Stryker Neuro Pi Drill Acceleration and Orque 100%
6. Pre-Incision Timeout (33 items)
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- ✓SURGEON: Welcome and Team introductions — name and role, names on white board
- ✓SURGEON: Briefing Begins: Patient/Family introduction and Surgical Plan, EBL
- ✓SURGEON: Reviews Preop Imaging — confirmed patient ID, levels, transitional anatomy
- ✓Circulating RN: Patient name and DOB confirmed with Anesthesia
- ✓Circulating RN: Surgery consent read aloud
- ✓Circulating RN: Allergies and Latex Allergies
- ✓Circulating RN: Positioning confirm legs/feet ok and strap on legs
- ✓ANESTHESIA: Antibiotic given within 1 hour of skin incision
- ✓ANESTHESIA: Positioning confirm OK — eyes, nose, mouth, bite block, ears, neck, arms/shoulders
- ✓ANESTHESIA: Warm all fluids, keep warmers on high until patient reaches 37C
- ✓ANESTHESIA: Minimize fresh gas flow to move bellows at 1 liter — optimize body temp
- ✓ANESTHESIA: TXA given and drip started at 50mg/kg, 5mg/kg/hr — run until PACU
- ✓ANESTHESIA: MAP in 70s during exposure, 80s during rod insertion
- ✓ANESTHESIA: Verbally report eyes, ET Tube and hands OK; EBL, MAP, PPV, TEMP, UO every 30 minutes
- ✓Circulating RN: If arms tucked, verbal “Hands OK” every 30 minutes
- ✓Circulating RN: Verbal “Legs OK” every 30 minutes
- ✓Timers set for every 30 minute anesthesia and foot/leg checks, 90 minute family call, 2 hour glove changes
- ✓ASSISTANT: Spinal red zone education L1 and above
- ✓NEUROMONITORING: Being performed and baseline readings obtained
- ✓Neuromonitoring Change Emergency Protocol review — Circulating Nurse will run, copies posted and available
- ✓Fire Safety Review: no alcohol/CHG pooling, prep dry, emergency checklist available
- ✓Safety zone and sharps awareness — pass blunt end first to table
- ✓Keep light handles 4 inches / 10cm above highest head — infection prevention
- ✓Confirm floor clear of trip hazards, all cables/tubes taped down
- ✓Verify bed location and label in case of emergency flip needed
- ✓Make sure everyone is double gloved
- ✓Minimize trips going in and out of room unless necessary
- ✓Sit down immediately if light-headed and notify staff — falls prevention
- ✓Keep talking and music to minimum to maximize communication and minimize distraction
- ✓Use verbal readbacks to ensure communication completed accurately
- ✓Any other team concerns?
- ✓Encourage all team members to speak up if there is concern or question
- ✓All team members agree with completed timeout and reply with “Aye”
7. Intraoperative (17 items)
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- ✓Skin incised lightly — surgical start time recorded
- ✓Circulating nurse calls family for first phone call, marked on board
- ✓Penfield 4 over transverse process for level confirmation, skin marked
- ✓Remove sucker-tip to avoid Betadine in cell saver
- ✓Incision covered with green towel and sponge placed in wound
- ✓Help X-Ray Tech align C-arm or X-Ray to decrease X-Ray exposure
- ✓AP/Lateral Fluoroscopy/X-Ray: confirm Penfield position above sacrum — confirmed by 3 team members
- ✓Facet joint and lamina marked with bur adjacent to Penfield 4
- ✓Marked level written on white board
- ✓Hemostasis check completed left side — every 10 cm during exposure each side
- ✓Vancomycin powder 1gm rubbed into muscle left side
- ✓Hemostasis check completed right side
- ✓Vancomycin powder 1gm rubbed into muscle right side
- ✓Exposure complete time recorded
- ✓Screw implant insertion begin time recorded
- ✓Pedicle screw placement safety subroutine — repeat for each screw
- ✓Each step called out verbally as completed to neuromonitoring and checklist team members
8. Finishing Screws and Confirming Imaging (5 items)
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- ✓All pedicle screws left side completed
- ✓All pedicle screws right side completed
- ✓Bilateral iliac wing screws completed if needed
- ✓Dilute Betadine solution and sponge in wound, sterile towel cover with marks
- ✓Fluoroscopic/X-Ray confirmation of screw position
9. Final Rods and Locking Checklist (5 items)
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- ✓Rods inserted bilaterally with multiple persuaders, compression and distraction
- ✓Time spine implants completed recorded
- ✓Ensure there is adequate rod sticking out each end, no muscle entrapment
- ✓Dilute Betadine placed in wound, incision covered and marked
- ✓X-rays confirming good coronal/sagittal balance and rod lengths
10. Prior to Closure Checklist (7 items)
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- ✓Screw caps double checked by surgeon and assistant with verbal check of each cap
- ✓Valsalva maneuver done to confirm no spinal fluid leak
- ✓Irrigate wound copiously with saline
- ✓Complete posterolateral decortication and place bone graft mixed with 2g Vancomycin
- ✓Meticulous hemostasis confirmed by careful wound inspection top to bottom bilateral
- ✓Blood Loss/Added recorded
- ✓Drain placement if needed
11. Closure (11 items)
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- ✓Note Closure Begin Time
- ✓Fascia closure at distal and proximal ends first then middle
- ✓Great care to ensure drain not sutured in — deep and superficial
- ✓Push down on wound to test for water-tight closure
- ✓Running #1 Vicryl or #2 Quill on fascia to further water-seal fascia
- ✓Confirm body weight then inject 0.5% Marcaine with epi up to 30cc if weight is 60kg or more
- ✓Incision Closed Time recorded — Surgery End
- ✓Dermabond and Steri-Strips applied and allowed to dry on incision
- ✓Confirm evoked potential and EMG monitoring was normal throughout surgery
- ✓Remove ALL non-disposables from drapes including bipolar, clips, cables
- ✓Pre-turn check for all lines/foley — loosen foley from table
12. Turn to Supine (11 items)
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- ✓Turn supine onto bed gently
- ✓Inspect face, arms, hands, chest, pelvis and lower extremity for skin/pressure/swelling
- ✓Patient opens eyes
- ✓Extubated Time recorded
- ✓Tongue check: no laceration
- ✓All neuromonitoring needles removed and accounted for
- ✓Patient moved bilateral lower extremities
- ✓Extubated and moving lower extremities — wakeup done
- ✓Time Patient Leaves Room — Wheels Out recorded
- ✓Complete Operative Note with merged checklist log, pasting into Hospital EHR
- ✓Ask for family to be put into consult room
13. Checkout and Debriefing (8 items)
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- ✓What went well in the surgery?
- ✓Complications?
- ✓Any equipment problems? — blank means no
- ✓Any preventable trips in and out of OR room?
- ✓Anything we could have done to make safer or more efficient?
- ✓Suggested changes to checklists?
- ✓Thank everyone for their help, recognizing them for things done well
- ✓Sustainability and Stewardship Waste Avoidance
