Preoperative Phase

The scheduler can positively identify the privileges that allow the surgeon to perform the procedure booked.

The scheduler can identify the expiration dates of any providers with fluoroscopy supervisor and operator licenses.

There is an order for any preoperative testing conducted (some labs may have been done prior to arrival or there is a protocol for certain patients that the nursing staff follows).

If there are protocols used, a copy of the protocol is placed on the medical record.

There is a preoperative nursing assessment completed according to policy.

The nursing assessment screens for risk of suicide.

The nursing assessment screens for abuse, neglect, exploitation.

Medication reconciliation is addressed prior to the procedure.

There is an informed consent for the procedure to be performed.

There is documentation that the procedural physician has explained the risks and benefits of the planned procedure.

There is a consent for anesthesia where an anesthesia professional has explained the risks and benefits of the planned anesthesia.

There is a preanesthesia assessment done within the 48 hours immediately prior to the administration of anesthesia that includes a review of the medical history, including anesthetic history, medication history and allergies(§482.52(b) (1)).

There is a preanesthesia assessment done within the 48 hours immediately prior to the administration of anesthesia that includes an interview (if possible depending on patient condition) and examination of the patient (§482.52(b) (1)).

There is a preanesthesia assessment done within 30 days of the administration of anesthesia that includes any additional potential anesthesia problems (e.g. difficult airway, ongoing infections, limited IV access).

There is a preanesthesia assessment done within 30 days of the administration of anesthesia that includes additional preanesthesia evaluation based on the patient's condition (e.g. stress test, labs, specialist consultation).

There is a preanesthesia assessment done within 30 days of the administration of anesthesia that includes plan for anesthesia care including types of medications for induction, maintenance and postoperative care as well as discussion with patient of risks and benefits of planned anesthesia.

The staff use clipper shavers for patients requiring hair removal. (should be done outside of the OR suite, just minor shaving should be done in the OR suite)

There is documentation of preoperative education of the patient regarding the procedure and postoperative experience.

The site is marked prior to the patient moving into the operating suite by the surgeon.

There is a preverification process that is followed.

Inspect anesthesia carts, emergency intubation boxes and other carts that store laryngoscopes and assure proper sterilization and storage of blades and disinfection of handles.

If a laryngoscope blade package is opened to check the bulb it must be resealed in package for storage to prevent recontamination (covered by cloth is no longer acceptable practice)

Assure medication safety - evaluate anesthesia carts for opened single use vials that should have been discarded.

Medication Safety - all multi-dose vials have open dates.

Medication safety - evaluate anesthesia carts for syringes with no labels and times as part of pre-op prep.

OR Techs check the wraps of sterile trays for holes.

Additional comments:

Intraoperative phase

Once the patient is brought into the operative suite, the patient is introduced to the team members.

The patient is properly prepped and draped (fire safety, IC). (dry time allowed before drape)

A timeout is conducted with the active participation of all team members.

An appropriate antibiotic is hung prior to first cut. This should be within 2 hours of incision.

Traffic is kept at an absolute minimum once the sterile field has been established.

An instrument count has been conducted and documented prior to the start of the case.

An instrument count is conducted when there is a change in surgical scrub techs during the case.

An instrument count is conducted when there is a change in the circulator during the case.

An instrument count is conducted prior to primary closing of fascia.

There is no final close of the patient until the count is correct.

The staff and surgeon can articulate the policy and process surrounding an irreconcilable count.

Specimens obtained during the procedure are labeled in the room with the patient.

Specimens are labeled with the correct patient and correct specimen type.

The sterile field is managed appropriately.

Instruments are wiped of excess organic material and saturated with enzymatic cleaner, prior to case instruments leaving room for reprocessing

At the conclusion of the case instruments for reprocessing are moistened with the appropriate enzymatic detergent prior to transport to decontamination. (no saline submersion of instrument, instruments cannot be transported in liquid).

At the conclusion of the case instruments for reprocessing are transported in a puncture proof case to decontamination.

The instrument transport cart is appropriately labeled as containing biohazardous material (Label/Sign)?

Additional comments:

Post opertive phase

There is handoff communication between the operative care staffs and anesthesia with the PACU nurse.

When a full operative or other high-risk procedure report cannot be entered immediately into the patient’s medical record after the operation or procedure, a progress note is entered in the medical record before the patient is transferred to the next level of care. This progress note includes the name(s) of the primary surgeon(s) and his or her assistant(s), procedure performed and a description of each procedure finding, estimated blood loss, specimens removed, and postoperative diagnosis.(RC.02.01.03 EP7)(§482.52(b) (1)).

The medical record contains the following postoperative information:
- The patient’s vital signs and level of consciousness (See also PC.03.01.05, EP 1; PC.03.01.07, EP 1)
- Any medications, including intravenous fluids and any administered blood, blood products, and blood components
- Any unanticipated events or complications (including blood transfusion reactions) and the management of those events

The medical record contains documentation that the patient was discharged from the post-sedation or postanesthesia care area either by the licensed independent practitioner responsible for his or her care or according to discharge criteria.

The medical record contains documentation of the use of approved discharge criteria that determine the patient’s readiness for discharge

The postoperative documentation contains the name of the licensed independent practitioner responsible for discharge.

There is a documented post anesthesia note within 48 hours that addresses the following:
- Respiratory function including respiratory airway patency and oxygen saturation
- Cardiovascular function including heart rate and blood pressure
- Mental status
- Temperature
- Pain
- Nausea and vomiting
- Post operative hydration

The hospital has a complete and up-to-date operating room register that includes the following:
- Patient's name
- Patient's hospital identification number
- Date of operation
- Inclusive or total time of operation
- Name of surgeon and any assistants
- Name of nursing personnel
- Type of anesthesia used and name of person administering it
- Operation performed
- Pre- and postoperative diagnosis
- Age of patient

For outpatients who underwent moderate sedation, deep sedation and/or anesthesia, they are discharged in the company of a responsible adult.

For outpatients who underwent moderate sedation, deep sedation and/or anesthesia, they are given discharge instructions related to the effects of the anesthesia.

For outpatients who underwent invasive procedure, education is provided regarding the signs and symptoms of infection and other complications, including who to notify.

Infection Prevention and Environment of Care

Operating Room Temperature is between 68 degrees F to 75 degrees F or 20 degrees C to 24 degrees C. (AORN Guidelines for Perioperative Practice (2017))

The OR temperature is:

The humidity of the operating room is between 20% and 60%.

The operating room is positively pressured in relation to the corridor.

Decontamination Room temperature is between 60 degrees F to 73 degrees F or 20 degrees C to 23 degrees C. (AORN Guidelines for Perioperative Practice (2017))

Decontamination Room Airflow pressure is NEGATIVE in relation to the corridor. (AORN Guidelines for Perioperative Practice (2017))

The Clean Workroom's temperature is 68 degrees F to 75 degrees F or 20 degrees C to 24 degrees C. (AORN Guidelines for Perioperative Practice (2017))

The Clean Workroom's humidity is a maximum of 60%. (AORN Guidelines for Perioperative Practice (2017))

The Clean Workroom is positively pressured in relation to decontam and corridor. (AORN Guidelines for Perioperative Practice (2017)).

Sterile Storage Room Temperature does not exceed 75 degrees F or 24 degrees C. (AORN Guidelines for Perioperative Practice (2017))

The Sterile Storage humidity is a maximum of 60%. (AORN Guidelines for Perioperative Practice (2017))

Sterile storage airflow pressure is POSITIVE in relation to the corridor. (AORN Guidelines for Perioperative Practice (2017))

Additional Infection Prevention and Control Observations:

Additional Environment of Care observations:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.