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BCCH SURGICAL SAFETY CHECKLIST – Audit Sheet

OR#:. BCCH SURGICAL SAFETY CHECKLIST – Audit Sheet. Date: . Procedure:. Surgeon:. Circ Nurse :. Anesthetist :. Service:. SIGN IN Initiated by Nurse. TIME OUT Initiated by Surgeon or Circ. Nurse. SIGN OUT Led by Circulating Nurse.

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BCCH SURGICAL SAFETY CHECKLIST – Audit Sheet

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  1. OR#: BCCH SURGICAL SAFETY CHECKLIST – Audit Sheet Date: Procedure: Surgeon: Circ Nurse: Anesthetist: Service: SIGN IN Initiated by Nurse TIME OUT Initiated by Surgeon or Circ. Nurse SIGN OUT Led by Circulating Nurse VERIFICATION STEPS VERBALIZED OUT LOUD FOR ALL TEAM MEMBERS TO REVIEW • When patient arrives in OR, • nurse verifies out loud: • Patient name • Procedure and site/side • Surgical site marked • Allergies • After induction, Surgeon or • Circulating Nurse verifies: • Patient identification/Consent • Procedure and Site/Side • Surgical site marked • Weight and Allergies • Antibiotics If required/indicated: • Equipment/implants/imaging • Specimens required? • Confirm blood available • STOP • Any concerns? • Circulating Nurse verifies: • Final Surgical counts • Specimen documentation • PSLS reports needed? Comments: Comments: Comments: □ Nursing □ Surgery □ Anesthesia □ Nursing □ Surgery □ Anesthesia □ Nursing □ Surgery □ Anesthesia Auditor: Revised: December 2011

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