General Hospital • Operating Theatre

Diathermy Safety Checklist

F-OT-18

Patient Name

MRN

Date

Surgeon

Procedure

ESU / Generator Asset ID

Electrosurgery Mode(s) Used

Monopolar Bipolar Adv. Bipolar/Ligasure

PM Valid?

Yes No (Do not use)

Safety Item to Check	Status	Remarks / Location
A. Pre-Use Equipment & Setup (Circulating/Scrub)
1. Active electrode (pencil) insulation intact; no exposed wires.	Yes No
2. Safety holster present on sterile field and used for active pencil.	Yes No
3. Footswitch (if used) protected from fluids and verified with surgeon.	Yes N/A
B. Return Electrode (Monopolar Pad) Management
4. Pad type matches patient (Adult vs Pediatric limits checked).	Yes N/A
5. Placed on clean, dry, well-perfused muscle (not over bone, scar, implant).	Yes N/A
6. Full contact verified; no wrinkling, tenting, or overlap.	Yes N/A
7. Placed away from ECG leads to prevent alternate-site burns.	Yes N/A
C. Fire & Surgical Smoke (Plume) Controls
8. Alcohol-based skin prep allowed to dry fully; no pooling observed.	Yes No
9. Smoke Evacuator setup, functional, and active during plume generation.	Yes N/A
10. Head/Neck/Oxygen-rich case? If yes, Fire Risk Pause conducted.	Yes N/A

Intra-Operative & Post-Operative Review

Power Settings Used (Initial)

Monopolar CUT

Monopolar COAG

Bipolar Setting

Post-Removal Pad Site Skin Assessment

Intact / Normal Excessive Redness Suspected Burn N/A (Bipolar only)

Alarms/Complications During Case?

SAFETY ALERT: Any suspected electro-thermal burn, equipment malfunction, or severe return-pad alarm must be treated as an incident. Remove the device and accessories from service immediately and tag for Biomedical investigation.

Circulating Nurse (Checker)

Name / ID

Signature

Surgeon Acknowledgement

Name / ID

Signature

Scrub Nurse (Sterile Setup)

Name / ID

Signature