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PRE-PROCEDURE CHECK IN
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Allergies reviewed
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Patient Identity Confirmed
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Procedure and Procedure Site Confirmed
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Surgical Consent
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Surgical Site
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History and Physical
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Pre-anesthesia assessment
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Nursing Assessment completed
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Diagnostic tests available
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Blood product availability
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Special devices and equipment availability
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Beta Blocker Meds Given
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Venous Thronboembolism
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Normothermia Confirmed
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Pulse OX placed
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Team Briefing
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TIME OUT
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Team Member introduction
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Surgical Site Confirmed
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Surgical Consent Confirmed
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Procedure and Procedure Site Confirmed
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Patient Identity Confirmed
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Fire Risk Confirmed
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Diagnostic tests available
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Special devices and equipment availability
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Critical Events by Surgeon
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Scrub and RN concerns
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Antibiotic Administration
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Time out completed by RN
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SIGN OUT
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Procedure as indicated in Consent
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Sponge Counts Correct
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Specimen Identified
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Equipment Problems Discussed
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Wound Classification
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Team Debriefing
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