Surgical Checklists & Briefings Observation Tool v1 Copy

• Document No.

• Conducted on

  Date

• Prepared by

• Hosptial Wing

  Atkinson Morley Wing

  St James Wing

  Lanesborough Wing

  Day Surgery Unit

• Theatre Complex

  Cardiothoracic Theatres

  Neurology Theatres

  Cardiology Cath Labs

  MRI

• Which Theatre

  Theatre 1

  Theatre 2

  Theatre 3

  Theatre 4

• Which theatre?

  Theatre 1

  Theatre 2

  Theatre 3

  Theatre 4

• Which Lab?

  Cath Lab 1

  Cath Lab 2

  Cath Lab 3

  Cath Lab 4

  Cath Lab 5

• Theatre Complex

  SJW Theatres

  Paul Calvert

  DSA

• Which theatre?

  Select Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre 5 Theatre 6 Theatre 7 Theatre 8

  • Theatre 1
  • Theatre 2
  • Theatre 3
  • Theatre 4
  • Theatre 5
  • Theatre 6
  • Theatre 7
  • Theatre 8

• Which theatre?

  Theatre 1

  Theatre 2

  Theatre 3

• Lanesborough Wing Theatres

  Maternity/Obstetrics

  CT/MRI

• Which theatre?

  Theatre 1

  Theatre 2

  Theatre 3

  Theatre 5

• Which theatre?

  Obstetrics 1

  Obstetrics 2

• Which Specialty is the operating list?

  Select Cardiac Thoracic Neurology Urology General Gynaecology Obstetrics Paediatrics Plastics Trauma Orthopaedic Spinal Neonatology Ears, Nose, Throat Maxillo Facial

  • Cardiac
  • Thoracic
  • Neurology
  • Urology
  • General
  • Gynaecology
  • Obstetrics
  • Paediatrics
  • Plastics
  • Trauma
  • Orthopaedic
  • Spinal
  • Neonatology
  • Ears, Nose, Throat
  • Maxillo Facial

• How would you describe this list

  Elective

  Urgent

  Emergency

• Who is the named Consultant for this List/Case?

• What time did the Theatre Briefing begin?

  Date

• Where was the Theatre Briefing conducted? ie. anaesthetic room, corridor etc

Please select the staff/personnel present at briefing

• Consultant Surgeon

• Surgical Registrar

• Consultant Anaesthetist

• Anaesthetic Registrar

• Anaesthetic Practitioner (ODP/Nurse)

• Surgical Scrub Lead Practitioner (Nurse/ODP)

• How many Scrub/Circulating staff are present (including Scrub Lead)?

  1

  2

  3

  4

  5

• Are there other personnel present?

  Yes

  No

• Role:

• Role

• Role:

• Add a photo of briefing, team and location

  Media

• Planned Surgical Procedure for all patients discussed?

  Yes

  No

• Please Comment

• Order of the list confirmed/discussed

  Yes

  No

  N/A

• What is the reason?

• Have all patients been seen by the anaesthetist?

  Yes

  No

  N/A

• Please comment

• Has equipment (including prosthesis & monitoring) been discussed and available

  Yes

  No

• Have any issues been identified?

  Yes

  No

• Have any post-operative requirements or special investigations been raised for any of the patients?

  Yes

  No

  N/A

• Please comment

• If there has been any equipment, post-op, patient, staffing or environmental issues raised, a named team member should be allocated to follow up & escalate their concerns.

  Off

  On

• On a scale of 1 - 10 how would you rank the briefing on quality and effectiveness? (1 Low -10 High)