Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
INFORMED CONSENT AND PATIENT EDUCATION
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Is there a completed procedural informed consent? <br>NOTE: Form must be signed, dated, timed & witnessed. <br><br>Hard Copy in procedural areas but are later scanned into EMR under Media
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Is there a completed sedation informed consent?
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Is there documentation of patient education?<br>NOTE: Pre-op / post-op education documented in patient chart<br><br>Discharge instructions in perioperative documents for Outpatient.
HISTORY & PHYSICAL
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H&P completed before surgery or procedure.<br>NOTE: H&P must be documented within 24 hours after admission to an inpatient unit and before surgery or procedure. Exception: H&P may be documented after the completion of an emergency procedure, but in no case more than 24 hours later.
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If the H&P was completed > 24 hours prior to procedure, is there an H&P Update? Note completed within 24 hours prior to procedure? <br>NOTE: H&P that is greater than 30 days old is considered invalid and may not be updated.
ANESTHESIA SEDATION ASSESSMENT
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Pre-anesthesia sedation health history assessment is completed within 48-hrs prior to surgery or procedure?<br>NOTE: Pre-anesthesia plan- anesthesia charting in EPIC
NATIONAL PATIENT SAFETY GOALS - PATIENT ID
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Checks patient identification band for patient name and date of birth and compares it to source document (MAR, lab label, requisition) when giving med, blood, obtaining specimens or before procedure? (OBSERVED)
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Staff utilize bar-coding device correctly (Observed)
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Specimens are labeled immediately after collection and in the presence of the patient (OBSERVED)
NATIONAL PATIENT SAFETY GOALS - PATIENT HAND-OFF
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Hand-off info includes information on patient’s condition, care, Rx, medications, services, recent or anticipated changes (OBSERVED)
NATIONAL PATIENT SAFETY GOALS - HAND HYGIENE
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Are staff using appropriate hand washing technique? (OBSERVED)
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5 moments: 1) Before patient care; 2) Before aseptic/sterile procedure; 3) After patient care; 4) After touching body fluids; 5) After touching patient equipment/environment (OBSERVED)
NATIONAL PATIENT SAFETY GOALS - MEDICATION
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Are syringes and/or containers labeled immediately after filling that are not being administered immediately? NOTE: Empty syringes may be labeled immediately before drawing up each syringe. Labeling is part of the medication preparation process and must be done at the same time the medication is prepared (drawn up into the syringe). Applying the label immediately before drawing up the medication is acceptable, so long as the label is prepared and applied at the time the medication or solution is prepared, and this is a continuous process with no interruptions. Otherwise, an empty syringe cannot be labeled before filling.
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Is IV tubing labeled per policy? (OBSERVED)
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Do mediation labels include: 1) medication name, 2) strength, 3) quantity (if not apparent from the container? NOTE: Additional required label elements, when applicable: 5) IV bag diluent for all compounded IV admixtures; 6) expiration date when not used within 24 hours; 7) expiration time when expiration occurs in less than 24 hours (e.g. propofol)
PRE-PROCEDURE VERIFICATION PROCESS
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When the patient is in the pre-procedure area, is a standardized list used to review and verify that the following items are available and accurately match the pt? NOTE: Preoperative Procedure Checklist
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Patient identity, procedure & side/site (if applicable) verified? (OBSERVED)
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Checks safety band for patient name and DOB and compares to source documentation ? (OBSERVED)
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Accurately completed and signed/dated/timed procedure consent form? <br>NOTE: Hard Copy in procedural areas but are later scanned into EMR under Media
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Correct and properly labeled diagnostic and radiology test results?<br>If applicable - hard copy and later scanned in EMR
SITE MARKING
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Is the procedure site marked with the provider’s initials?
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Is site marked before the patient is moved to the procedure location?<br>NOTE: Proceduralist does marking & prior to time-out.
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Site marked by licensed independent practitioner ultimately accountable.
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Does the marking take into consideration laterality (left or right), the level (spine), or specific digit/lesion to be treated?
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For procedures that involve laterality of organs, but the incision(s) or approaches may be mid-line, is the site marked and the laterality noted?
TIME-OUT
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Is time-out conducted prior to starting procedure?<br>NOTE: Ideally, prior to introduction of anesthesia (including general/regional local, and spinal anesthesia).
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Does the time-out have the following characteristics:
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Involves the immediate members of the procedure team including the proceduralist(s) - can be the fellow, the anesthesia providers, the circulating nurse, the OR technician, and other participants as appropriate for the procedure.
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Involves interactive verbal communication between all team members. NOTE: During a time-out, all other activities are suspended. No multitasking!
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Does the time-out have all of the following 10 items:
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Correct patient identification
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Confirmation that correct site & side are marked
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An accurate and completed procedural consent form
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Agreement on procedure(s) to be performed
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Site mark visible after prep and draping
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Resolution of any conflicts in information
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Relevant diagnostic / radiological studies if applicable
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Verification of needed antibiotics, irrigation fluids, or medications
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Availability of anticipated implants and special equipment
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Safety precautions based on patient history and/or medication use
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Was the time-out documented? NOTE: Intra-op documentation in EPIC
IMMEDIATE POST-OP/POST-PROCEDURE NOTE
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Immediate post-op/post-procedure noted completed prior to the patient moving to the next level of care? NOTE: The report may be written in the next area of care if the proceduralist accompanies the patient to the next level of care. Brief Operative Note may also be documented as a “procedure note.” Op Note in EPIC
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Does the immediate post-op note address all 6 required elements:1) Surgeon and assistant(s) names, 2) procedure, 3) finding(s), 4) post-op diagnosis, 5) estimated blood loss, 6) specimens? NOTE: Must be written before transfer to next level of care.
DOCUMENTATION
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Every signature is dated and timed
DESCRIBE THE UNIT'S RESPONSE TO YOUR ARRIVAL
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Was the team greeted with smiles & introductions?
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Was a space provided and dedicated for the team to conduct interviews and file reviews?
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Were questions answered promptly or materials required for review delivered to the tracer team?
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This tracer was WITHOUT any additional comments regarding positive or suboptimal issues observed during this tracer?
