The World Health Organization encourages organizations to adapt the WHO Surgical Safety Checklist to their own needs (subject to certain requirements).
To help organizations come up with their ideas for how to adapt the checklist for use in their own facility, the WHO offers this list of viewable, adapted checklists from organizations including the Mayo Clinic, Children's Hospital Boston and Gundersen Lutheran Health System.
If organizations intend to adapt the checklist, the WHO offers this adaptation guide (pdf).