F-15
Stop Before You Block
دليل السياسات والإجراءات في التخدير — Section M

Form F-15 Preview

Stop-Before-You-Block Time-Out (Regional Anesthesia)

[HOSPITAL NAME]

Department of Anesthesia • Regional Service

FORM F-15

Document to Medical Record

Critical Safety Check

Stop Before
You Block

Time-Out Verification

Affix Patient Label Here
Name:
MRN:
DOB:
Location (Select One)
Date
Time
Planned Surgery / Procedure
Block Type (e.g., Interscalene, Spinal, TAP)
Block Laterality (MANDATORY)
Specific Anatomical Site
✔
Mandatory Verification (Complete BEFORE needle insertion)
1. Two patient identifiers confirmed
2. Consent confirmed (Regional + anesthesia if required)
3. Site mark visible and correct side exposed
4. Allergies reviewed Latex: | Chlorhexidine:
5. Anticoagulation / antiplatelet status reviewed and OK to proceed
6. Baseline neuro exam documented (for limb block)
7. Monitoring applied (NIBP / SpO₂ / ECG as appropriate)
8. Oxygen & suction immediately available
9. LAST rescue kit + 20% lipid available and in date
10. Local anesthetic dose plan calculated & within maximum safe limit

STOP

IF ANY ITEM ABOVE IS "NO" → DO NOT PROCEED.

Escalate to Anesthesia Consultant immediately.

Block Performer (Anesthesia Provider)

Signature / Print Name

Assistant / Witness (Nurse / Tech)

Signature / Print Name

Time Completed
Form F-15 | Page 1 of 1