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
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Auditor Name
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Wing
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Theatre
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- Theatre 1
- Theatre 2
- Theatre 3
- Theatre 4
- Theatre 5
- Theatre 6
- Theatre 7
- Theatre 8
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- Theatre 1
- Theatre 2
- Theatre 3
- Theatre 5
- Obstetric 1
- Obstetric 2
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What Specialty is it?
- Cardiac
- Thoracic
- Vascular
- Cardiology
- Neurology
- Spinal
- Urology
- Pain
- Paediatric
- Orthopaedic
- Trauma
- Plastics Trauma
- General
- Ear, Nose Throat
- Obstetrics
- Gynaecology
- Neo-natal
- Other
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If other what is it?
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What is the name of the Consultant on the list?
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Select date
Setting
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Select date
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Where was the briefing conducted? ie. Anesthetic Room, Corridor etc.
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What personnel are present?
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Consultant Surgeon
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Surgical Registrar
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Consultant Anaesthetist
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Anaesthetic Registrar
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Anaesthetic Practitioner (ODP/Nurse)
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Theatre Scrub Lead 1
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Scrub/Circulating Staff 2
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Scrub/Circulating Staff 3
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Other
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Role:
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Role:
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Role:
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Add photo of team & location
Briefing
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Planned Surgical Procedure for all patients discussed?
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Order of the List Confirmed
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What is the reason? ie. only 1 patient
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Has the Patient's been reviewed by the anaesthetist?
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If no or n/a, why? ie. Patients not here or Local Anaesthetic only
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Has equipment been discussed?
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Have any equipment issues been identified?
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The team need to have agreed how and who to escalate this to by an identified team member.
