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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