Situation: A 41-year-old woman is scheduled for elective open abdominal surgery under general anesthesia, with the skin incision planned for 09:30 tomorrow. Cefazolin 2 g intravenous (IV) is ordered as surgical antibiotic prophylaxis. She has no known drug allergies. The hospital uses the World Health Organization (WHO) Surgical Safety Checklist. In which phase does the nurse verbally confirm with the team that the instrument, sponge, and needle counts are complete?

The WHO Surgical Safety Checklist has three phases: sign in before induction of anesthesia, time out before the skin incision, and sign out before the client leaves the operating room. At sign out the nurse confirms the procedure name, the instrument, sponge, and needle counts, specimen labeling, and any equipment problems.

Understanding the WHO Surgical Safety Checklist phases

The WHO Surgical Safety Checklist is a three-phase communication tool designed to catch errors at critical transition points during surgery. The phases are sign in (before induction of anesthesia), time out (immediately before skin incision), and sign out (before the patient leaves the operating room). Each phase has a distinct focus and set of verbal confirmations.

The instrument, sponge, and needle count confirmation belongs specifically to the sign out phase, not to time out or sign in. At sign out, the nurse verbally reviews with the entire team the name of the procedure performed, completion of instrument/sponge/needle counts, correct labeling of any surgical specimens, and any equipment problems that need to be addressed. This timing makes clinical sense: the count is only meaningful after the incision has been closed and the surgical field is no longer being manipulated, which is why it occurs before the patient leaves the OR rather than before the incision.

Watch out! Do not confuse time out with sign out. Time out occurs before the skin incision and focuses on confirming patient identity, procedure, site, and antibiotic prophylaxis—not on counts. The cefazolin in this scenario would be verbally confirmed during time out, while the count confirmation belongs to sign out.

Why sign out is the correct phase

The sign out phase serves as the final safety net before the patient leaves the controlled OR environment. It is performed with the surgeon, anesthesia provider, and nursing team all present. The nurse leading the checklist reads aloud each item, and the team verbally confirms. The count of instruments, sponges, and needles is a core nursing responsibility because retained surgical items are a preventable but serious patient safety event.

Evidence consistently shows that sign out is the most poorly performed phase of the WHO checklist, often due to high workload, team fatigue, and the natural rush to complete the case. One study noted that sign out coincides with a period of high workload for team members, which may explain lower compliance compared to sign in and time out ^[1]. Another protocol paper highlighted that adherence to the third part of the checklist—sign out—is low, and that intraoperative adverse events are not routinely assessed during this phase despite its importance . This does not change the fact that sign out is where counts are confirmed; rather, it underscores why nurses must be deliberate and not skip this step.

Key point! The count confirmation is a nursing-led verbal check during sign out. Even if the circulating nurse and scrub nurse have already counted together, the formal verbal confirmation with the whole team—including the surgeon—is what the WHO checklist requires at sign out. This shared verbal confirmation closes the loop and allows any discrepancy to be addressed before the patient leaves the OR.

Applying this to the clinical scenario

In this case, the patient is having elective open abdominal surgery with a skin incision planned for 09:30. The nurse would participate in sign in before anesthesia induction, confirming patient identity, consent, allergies, and the anesthesia plan. At time out, just before the 09:30 incision, the team would pause to confirm the correct patient, correct procedure, correct site, and that cefazolin 2 g IV has been administered. Then, after the abdominal cavity is closed and before the patient is transferred from the OR table, the team performs sign out, where the nurse verbally confirms that instrument, sponge, and needle counts are complete and correct.

The distinction between the phases is not merely academic. Each phase targets a different type of error: sign in targets wrong-patient and anesthesia errors, time out targets wrong-site and wrong-procedure errors, and sign out targets retained items, specimen errors, and equipment problems. Understanding this framework helps prioritize nursing actions at each transition point.

Checklist fidelity and nursing implications

Research on checklist implementation fidelity emphasizes that simply having a checklist is not enough—the quality of team communication and engagement during each phase matters . A prospective observational study in Ethiopia found variable adherence to the WHO checklist across its 19 items, reinforcing that nurses must actively lead and advocate for complete checklist performance rather than treating it as a formality . For the sign out phase specifically, the nurse should ensure the surgeon pauses and the anesthesia provider is present before reading the count confirmation aloud.

The nurse's role at sign out is to verbally confirm counts with the team, not to assume the count is correct simply because the scrub nurse and circulating nurse have already counted together. The verbal confirmation creates a shared mental model and gives the surgeon an opportunity to report any known issue, such as a sponge intentionally left in place or a needle that broke during closure.