Surgical Procedure Checklist - Minnesota Hospital Association
SAFE Account Audit Form (sample items)
Date ____________________OR # Procedure
Surgeon Anesthesia Care Provider
Room Staff (RN) Room Staff (ST)
|Operating Room — Pre-Procedure |
|1. Surgical Suite inspection accomplished per policy |( ) Yes ( ) No |
|2. Baseline count: | |
|* Conducted by an RN and one other person |( ) Yes ( ) No |
|* Both individuals viewed and verbally counted each item |( ) Yes ( ) No |
|* Counting was done in order specified in policy |( ) Yes ( ) No |
|* Items inspected for radiopaque marker as part of count process |( ) Yes ( ) No |
|* Listed on: white board____ or count sheet________ |( ) Yes ( ) No |
|* Documented in medical record |( ) Yes ( ) No |
|3. * Room is free of distractions during count |( ) Yes ( ) No |
|* If there were distractions, count was redone |( ) Yes ( ) No ( ) NA |
| |
|Operating Room — During Procedure |
|Items added during the procedure were counted and listed |( ) Yes ( ) No |
|Tucked items were communicated and listed on whiteboard or count sheet |( ) Yes ( ) No ( ) NA |
|Packed items were communicated |( ) Yes ( ) No ( ) NA |
|Sponges remained intact, i.e., were not cut |( ) Yes ( ) No |
|Equipment was inspected for intactness prior to and after use |( ) Yes ( ) No |
|Counts were performed at appropriate points in the procedure, i.e., before closure of a cavity within a cavity, at | |
|time of permanent staff relief |( ) Yes ( ) No |
| | |
|Operating Room — End of Procedure |
|Items placed during the procedure intended for removal prior to wound close | |
|were removed |( ) Yes ( ) No ( ) NA |
|Final counts: | |
|* Used sponges/soft goods were unballed and pulled apart prior to count |( ) Yes ( ) No |
|* Counting done in order per policy |( ) Yes ( ) No |
|A methodical wound exploration was accomplished prior to closure |( ) Yes ( ) No |
|If all items not accounted for, reconciliation per hospital policy occurred |( ) Yes ( ) No |
|If items could not be reconciled, intraoperative images were obtained with review by surgeon and radiologist | |
| |( ) Yes ( ) No |
|Placed items intended for removal in the postop period were communicated to the next level of care | |
| |( ) Yes ( ) No |
|A final surgical suite inspection was accomplished |( ) Yes ( ) No |
Reviewer:
Comments:
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SAFE
ACCOUNT
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