AORN Comprehensive Surgical Checklist 2019 PDF

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COMPREHENSIVE SURGICAL CHECKLIST Blue = World Health Organization (WHO)

Green = The Joint Commission - Universal Protocol 2016 National Patient Safety Goals

PREPROCEDURE CHECK-IN In Preoperative Ready Area

SIGN-IN Before Induction of Anesthesia

Patient or patient representative actively RN and anesthesia professional confirm: confirms with registered nurse (RN):

Teal = Joint Commission and WHO

TIME-OUT

SIGN-OUT

Before Skin Incision

Before the Patient Leaves the Operating Room

Initiated by designated team member: All other activities to be suspended (except in case

RN confirms:

of life-threatening emergency) Identity  Yes Procedure and procedure site  Yes Consent(s)  Yes Site marked  Yes  N/A by the person performing the procedure RN confirms presence of: History and physical  Yes Preanesthesia assessment  Yes Nursing assessment  Yes Diagnostic and radiologic test results  Yes  N/A Blood products  Yes  N/A Any special equipment, devices, implants  Yes  N/A

Include in Preprocedure check-in as per institutional custom: Beta blocker medication given  Yes  N/A Venous thromboembolism prophylaxis ordered  Yes  N/A Normothermia measures  Yes  N/A

Confirmation of the following: identity, procedure, procedure site, and consent(s)  Yes Site marked  Yes  N/A

Introduction of team members  Yes

Name of operative procedure:

All: Confirmation of the following: identity, procedure, incision site, consent(s)  Yes

Completion of sponge, sharp, and instrument counts  Yes  N/A

by person performing the procedure

Site is marked and visible  Yes  N/A

Specimens identified and labeled

Patient allergies  Yes  N/A

Fire Risk Assessment and Discussion

 Yes  N/A

Pulse oximeter on patient  Yes

 Yes (prevention methods implemented)

Difficult airway or aspiration risk

 N/A

Equipment problems to be addressed  Yes  N/A

 No  Yes (preparation confirmed) Risk of blood loss (> 500 mL)

Relevant images properly labeled and displayed  Yes  N/A

 Yes  N/A

Any equipment concerns  Yes  N/A

To all team members:

# of units available

Anticipated Critical Events

What are the key concerns for recovery

Anesthesia safety check completed

Surgeon: States the following:

and management of this patient?

 Yes

 Critical or nonroutine steps

Briefing:

 Case duration

All members of the team have discussed care plan and addressed concerns  Yes

 Anticipated blood loss

Discussion of Wound Classification  Yes

Anesthesia professional: Antibiotic prophylaxis within 1 hour before incision Debriefing with all team members:  Yes  N/A Opportunity for discussion of Additional concerns  Yes  N/A − team performance Scrub person and RN circulator: − key events Sterilization indicators confirmed  Yes − any permanent changes in the Additional concerns  Yes  N/A preference card RN: Documented completion of time out  Yes

Th e Jo in t C o mm issio n d o e s n o t stip u l a te w h ich te a m me m b e r in iti a te s a n y se ct io n o f t h e ch e cklis t e xce p t f o r site ma rkin g . Th e J o in t Co m missio n a lso d o e s n o t s tip u l a te wh e re th e se a cti vitie s o c cu r. S e e th e U n iv e rsa l Pro to co l f o r d e t a ils o n t h e Jo in t Co mm issio n re q u ire m e n ts .

January 2019...