PreOp verification/Time Out Audit - Local

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

PreOp verification by OR staff

• Images are checked and are available?

  Yes

  No

  N/A

• Special equipment/instruments/supplies are checked and are available?

  Yes

  No

  N/A

• Implants are checked and are available?

  Yes

  No

  N/A

• Antibiotics have been given on time.

  Yes

  No

  N/A

PreOp verification by patient

• Patient is asked name, DOB, MD while nurse checks Name band and chart.

  Yes

  No

  N/A

• Patient is asked what procedure they are having done while nurses checks consent?

  Yes

  No

  N/A

• Patient is asked what allergies they have while nurse checks documentation in the chart.

  Yes

  No

  N/A

• Patient is asked to state what site the surgery is on while nurse checks consent and the chart.

  Yes

  No

  N/A

Time Out

• Surgeon calls for time out just prior to incision.

  Yes

  No

  N/A

• All other activity ceases, every one focuses on Time Out.

  Yes

  No

  N/A

• Circulator reads aloud the patient's name, procedure and procedure site from the informed consent. Asks for verification.

  Yes

  No

  N/A

• CRNA states patient name and procedure and site.

  Yes

  No

  N/A

• Scrub person states which procedure they have prepped for, including site.

  Yes

  No

  N/A

• Scrub person looks at site marking and states she sees it and where it is located.

  Yes

  No

  N/A

• Surgeon states full procedure.

  Yes

  No

  N/A