PatientName:
Beforeinduction of anesthesia (maybedonebeforeOR entry)
Has the patient confirmedhis/her identity, site, procedure,andconsent? Yes
Is the sitemarked? Yes N/A
Anesthesia provider Anesthesia safety check completed
Difficult airwayor aspiration? Yes No
Are thereany anesthesia specific concerns?
_____________________________________ Riskof>10%bloodvolume loss? Yes, and two IVs/central access and fluids planned
No
Is venous thromboembolismprophylaxis needed? Yes, and boots/
Yes, type and screen ordered? N/A N/A
anticoagulants in place Surgeon: What implants/equipment areneeded?
_____________________________________ Nursing Team: Are there equipment issues orany concerns? Yes N/A
_____________________________________ Is essential imaging displayed/PACS/C-arm available? Yes N/A
BEFORE INDUCTION check complete
ProcedureScheduled: Beforeskin incision
Circulator–TIMEOUT! Weneedtodoa timeout.
FIRE RISK Score documented? Yes
Has sterility (includingindicator results)beenconfirmed? Yes
Surgeon, anesthesia andnurse: What is the patient’s name? What procedure is planned? Is the patient in the correct position?
Circulator toSurgeon: Howlongwill the case last? What is the anticipated blood loss? Are there any critical steps?
Does the patienthave a knownallergy? Yes No
Has antibiotic prophylaxis been givenwithin the last 60 minutes? Yes N/A
Doesanyonehaveany concerns? Yes No
______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________
BEFORE SKIN INCISON check complete
Checklist based onW.HO. Surgical Safety Checklist (First Edition), from theW.H.O. ImplementationManual June 2008. All reasonable precautions have been taken by theWorld Health Organization and Healthcare Inspirations to verify the information contained in this checklist. However, the pub- lished material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall theWorld Health Organization or Healthcare Inspirations be liable for damages arising from its use.
Raytec: Lap sponges: Needles: Blades: Kittners: Hypodermics: Cautery tips:
BEFORE LEAVING ROOMcheck complete ©Healthcare Inspirations. All rights reserved. To order, (877) 646-5877 •
HealthcareInspirations.com
Diet Nothing by Mouth Beforepatient leaves room
Nurse verbally requests fromthe team: Howshall I record the name of the procedure? Howshall I label the specimens (including patient name)?
To surgeon, anesthetist andnurse: What are the key concerns for recovery and management of this patient?
Are any equipment problems to be addressed? Is there anything thatwe could have done better? Debrief formcompleted, if indicated?
Are the instrument, spongeand needle counts complete/correct?
12 3
Regular Full Liquid Clear Liquid
Activity Level
Independent Walker Stand by
Lift Equipment 1 Person
2 Person
Samples Needed Random
24 Hour C.diff Sputum 36”x 24” TopperOverlay Surgical Safety Checklist 11”x 17” TopperOverlay
We have received rave reviews fromour moms on ourMom- Baby Unit about the white boards. They really love themand the information pro-
vided to them. CHIEFNURSE EXECUTIVE
PROVIDENCEALASKA MEDICAL CENTER
O.B. Wound
© Healthcare Inspirations. All rights reserved. (877) 646-5877. Re-Order ID: 1357238 Trauma M/S; 11x17” v2 08/2013.
Diabetic Dysphagia Soft
No Exceptions Except Meds Except Ice Except Sips
Spinal Precaution
Full Spinal C-spine
C-spine cleared with collar
T-spine Precaution
PatientAlerts
24”x 18” shown in Cherrywood, 1-1/4” profile
Rehabilitation
Learnmore at
HealthcareInspirations.com 25
SURGICAL SAFETYCHECKLIST
Other
Stool
Urine
Stop Start
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28