Title Page

  • Medical Record Number:

  • Patient Name:

  • Type of Surgery:

  • Date/Time of Surgery:

  • Surgeon:

  • Location:
  • Assisting Personnel:

Before induction of anaesthesia

  • Has the patient confirmed his/her identity, site, procedure, and consent?

  • Is the site marked?

  • Is the anaesthesia machine and medication check complete?

  • Is the pulse oximeter on the patient and functioning?

  • Does the patient have a:

  • Known allergy?

  • Difficult airway or aspiration risk?

  • Risk of >500ml blood loss (7ml/kg in children)?

Before skin incision

  • Confirm all team members have introduced themselves by name and role

  • Confirm the patient's name, procedure, and where the incision will be made

  • Had antibiotic prophylaxis have been given within the last 60 minutes?

Anticipated Critical Events

  • To Surgeon:

  • What are the critical or non-routine steps?

  • List critical or non-routine steps

  • How long will the case take?

  • Include estimated time

  • What is the anticipated blood loss?

  • Include blood loss estimate

  • To Anaesthetist:

  • Are there any patient specific concerns?

  • To Nursing Team:

  • Has sterility (including indicator results) been confirmed?

  • Are there equipment issues or any concerns?

  • List concerns

  • Is essential imaging displayed?

Before patient leaves operating room

  • Nurse Verbally Confirms:

  • The name of the procedure?

  • Completion of instrument, sponge and needle counts

  • Specimen labelling (read specimen labels aloud, including patient name)

  • Whether there are any equipment problems to be addressed

  • To Surgeon, Anaesthetist and Nurse:

  • Are there any key concerns for recovery and management of this patient?

  • Surgeons name and signature

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