Surgical Safety Checklist
(verified by medical assistant, nurse, physician)
Prior to sedation (if necessary) and procedure:
- Safety checks performed and all equipment is working well, including 0 2 and suction.
- Confirm patient identity using two identifiers (name, date of birth); confirm procedure with patient Equipment is available as requested for the case
- Anesthesia personnel are utilizing VS monitors to record ECG, BP, pulse oximetry, etc.
- Patient allergies, NPO status, and pregnancy status completed if applicable Presence of responsible party to escort patient home, if necessary
- Antibiotics were administered within 60 minutes of procedure time if applicable
Prior to start of procedure:
- All team members have introduced themselves by name/role Consent form has been signed
- Anesthesia pre -procedure assessment and H&P have been appropriately completed
- Again, confirm patient identity using two identifiers (name, date of birth); confirm procedure with patient Airway or aspiration risk determined , preparation confirmed. Bag valve mask is present
- Instruments and equipment were reprocessed appropriately No question or concerns of any team member or patient
After completion of procedure and before patient leaves to procedure room:
- Procedure was performed
- Any problems with equipment were addressed and noted
- No key concerns for recovery other than those otherwise noted
Signature (Print Full Legal Name)
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