Form F-08 Preview

OR Sign-In / Time-Out / Sign-Out (Landscape intended)

[HOSPITAL NAME]

Surgical Safety & Quality

Surgical Safety Checklist

Sign-In | Time-Out | Sign-Out

FORM F-08

Patient Name & Label Area

Affix Label

Name:

MRN:

Date

OR / Room No.

Planned Procedure

Before Induction

SIGN-IN (Nurse & Anesthesia)

Has the patient confirmed his/her identity, site, procedure, and consent?

Yes

Is the surgical site marked?

Yes Not Applicable

Is the anesthesia machine and medication check complete?

Yes

Is the pulse oximeter on the patient and functioning?

Yes

Patient Risks Does the patient have a known allergy?

No Yes:

Difficult airway or aspiration risk?

No Yes, and equipment/assistance available

Risk of >500ml blood loss (7ml/kg in children)?

No Yes, and two IVs/fluids/blood planned

Before Skin Incision

TIME-OUT (Entire Team)

Confirm all team members have introduced themselves by name and role. Surgeon, Anesthesia, and Nurse verbally confirm:

Patient Site Procedure

Anticipated Critical Events To Surgeon: What are the critical or non-routine steps? How long will the case take? What is the anticipated blood loss? To Anesthesia: Are there any patient-specific concerns? (Comorbidities, hemodynamics) To Nursing Team: Has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns?

Has antibiotic prophylaxis been given within the last 60 minutes?

Yes Not Applicable

Is essential imaging displayed?

Yes Not Applicable

Before Leaving OR

SIGN-OUT (Nurse, Surgeon, Anesth)

Nurse Verbally Confirms: The name of the procedure recorded. Completion of instrument, sponge and needle counts.

Correct Not App.

Specimen labeling (read specimen labels aloud, including patient name). Whether there are any equipment problems to be addressed.

Post-Op Recovery & Management Surgeon, Anesthesia Professional, and Nurse review the key concerns for recovery and management of this patient.

Destination: PACU ICU

Key concerns:

Circulating Nurse Signature

Surgeon Signature

Anesthesia Provider Signature