Surgical Procedure Checklist
Pre-Procedure Verification Auditing Form
Date ________________________________ Procedure
Physician ___________
Room Staff (RN) Room Staff (Tech)
|Pre-Procedure |
|1. Patient identification verified using two indicators |( ) Yes ( ) No |
|2. Procedure verified using at least two independent source documents |( ) Yes ( ) No |
|Source documents used: | |
| | |
|3. Procedure verified by at least two independent reviewers |( ) Yes ( ) No |
|Staff roles performing verification: | |
| | |
|4. Site Marking |( ) Yes ( ) No ( ) N/A |
|a. Site marked by person performing the procedure | |
| b. Site marked with initials of person performing procedure |( ) Yes ( ) No ( ) N/A |
| c. Multiple sites labeled in the medical record and marked accordingly |( ) Yes ( ) No ( ) N/A |
|d. Diagram marked by person performing procedure if unable to mark on patient or mark not visible with draping | |
|Site was not marked due to: |( ) Yes ( ) No ( ) N/A |
|( ) Site marking not required per policy | |
|( ) Provider is in continuous attendance with the patient | |
|( ) Refused by patient | |
|Procedure Room |
|1. Team communication completed |( ) Yes ( ) No |
|2. Team communication included all team members actively involved in case |( ) Yes ( ) No |
|Team members included: | |
| | |
|Information reviewed: | |
|( ) Images and diagnostic/pathology/lab reports | |
|( ) Implants or special equipment | |
|( ) Antibiotics or fluids for irrigation | |
|( ) Positioning | |
|( ) Additional safety precautions: | |
|3. Time-out visual reminder in place prior to procedure |( ) Yes ( ) No |
|Just Prior to Procedure |
|1. Person performing procedure initiated the time-out verbally |( ) Yes ( ) No |
|2. All other activity ceased |( ) Yes ( ) No |
|3. 2nd health care provider verbally verified patient & procedure including side/site |( ) Yes ( ) No |
|4. 2nd health care provider verbally verified visualization of mark |( ) Yes ( ) No |
|5. Person performing procedure verbally verified procedure including side/site |( ) Yes ( ) No |
Notes/Comments:
Auditor Name:
Date:
................
................
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