Title Page
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Type of Surgery:
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Date/Time of Surgery:
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Nursing Team:
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Anaesthetist:
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Surgeon:
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Location:
Before induction of anaesthesia
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(with at least nurse and anaesthetist)
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Has the patient confirmed his/her identity, site, procedure, and consent?
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Is the site marked?
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Is the anaesthesia machine and medication check complete?
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Is the pulse oximeter on the patient and functioning?
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Does the patient have a:
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Known allergy?
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Difficult airway or aspiration risk?
- No
- Yes, and equipment/assistance available
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Risk of >500ml blood loss (7ml/kg in children)?
- No
- Yes & two IVs/central access & fluids planned
Before skin incision
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(with nurse, anaesthetist and surgeon)
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Confirm all team members have introduced themselves by name and role
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Confirm the patient's name, procedure, and where the incision will be made
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Had antibiotic prophylaxis have been given within the last 60 minutes?
Anticipated Critical Events
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To Surgeon:
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What are the critical or non-routine steps?
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List critical or non-routine steps
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How long will the case take?
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Include estimated time
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What is the anticipated blood loss?
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Include blood loss estimate
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To Anaesthetist:
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Are there any patient specific concerns?
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To Nursing Team:
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Has sterility (including indicator results) been confirmed?
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Are there equipment issues or any concerns?
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List concerns
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Is essential imaging displayed?
Before patient leaves operating room
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(with nurse, anaesthetist, and surgeon)
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Nurse Verbally Confirms:
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The name of the procedure
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Completion of instrument, sponge, and needle counts
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Specimen labelling (read specimen labels aloud, including patient name)
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Whether there are any equipment problems to be addressed
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To Surgeon, Anaesthetist, and Nurse:
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Are there any key concerns for recovery and management of this patient?
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List concerns
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Surgeon name and signature
