Surgical Procedure Checklist - MHA
Pre-Procedure Verification Checklist
Invasive Procedures Outside the Operating Room
If at any time during this process, there is a discrepancy of information, call for a “Hard Stop” – all activity ceases until information is reconciled.
|Pre-Procedure – Verification | | |
|Patient identification verified using two indicators | | |
|Accurate and complete informed consent verified | | |
|Procedure verified using at least two independent source documents | |
|Provider order, diagnostic images, radiology/pathology reports, patient understanding of the procedure, informed consent | |
| | | |
| | |
|Site marked, as appropriate*, by person performing the procedure with initials: | | |
|*Refer to provider policy for site marking exclusions | | |
| | | |
|Multiple sites marked and identified in the informed consent | | |
| | | |
|Diagram marked by person performing the procedure if unable to mark on patient…….. | | |
|Site was not marked due to: | | |
|( ) Site marking not required per policy | | |
|( ) Provider is in continuous attendance with the patient | | |
|( ) Refused by patient | | |
| | | |
|Health Care Provider Signature: | | |
| | | |
|Pre-Procedure – Communication | | |
|Team communication completed | | |
| | | |
|Team reviewed relevant case information including: | | |
| | | |
|- Images and diagnostic/pathology/lab reports Yes ( ) N/A ( ) | | |
|- Anticipated equipment is available Yes ( ) N/A ( ) | | |
|- Antibiotics or fluids for irrigation Yes ( ) N/A ( ) | | |
|- Positioning Yes ( ) N/A ( ) | | |
|- Additional safety precautions, e.g. allergies Yes ( ) N/A ( ) | | |
| | | |
|Just Prior to Procedure (Time-out) | | |
|Person performing the procedure initiated the time-out verbally | | |
| | | |
|All other activity ceased | | |
| | | |
|2nd health care provider verbally: | | |
|Verified patient and procedure including side/site | | |
|Verified visualization and location of the site mark, if applicable | | |
| | | |
|Person performing the procedure verbally: | | |
|Verified procedure including side/site | | |
|Health Care Provider Signature: | | |
| | | |
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