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Patient has confirmed: Identity Site Procedure Consent Site Marked/Not Applicable

Patient has confirmed: Identity Site Procedure Consent Site Marked/Not Applicable Anesthesia Safety Check completed Pulse oximeter on patient and functioning UNOS ID# (If applicable) Does patient have a known allergy? No Yes Drugs Latex Other:__________________

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Patient has confirmed: Identity Site Procedure Consent Site Marked/Not Applicable

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  1. Patient has confirmed: • Identity • Site • Procedure • Consent • Site Marked/Not Applicable • Anesthesia Safety Check completed • Pulse oximeter on patient and functioning • UNOS ID# (If applicable) Does patient have a known allergy? • No • Yes • Drugs • Latex • Other:__________________ Difficult Airway/Aspiration Risk? • No • Yes, & equipment/assistance available Risk of >500ML Blood Loss • No • Yes, and adequate intravenous access and fluids planned Blood bank notified & Blood available? Conversion equipment readily available? (Robotic, minimally invasive cases) • Confirm all team members have introduced themselves by name and role • Surgeon, Anesthesia Professional and Nurse verbally confirm: Anticipated Critical Events • Surgeon Reviews: • Critical or unexpected steps, Airway or Ventilatory issues • Operative Duration, Anticipated blood loss? Fluid Management Anesthesia Team Reviews: • Any patient-specific concerns? Nursing Team Reviews: • Has sterility (including indicator results) been confirmed? • Are there equipment issues or any concerns? Has antibiotic Prophylaxis been given within the last 60 minutes? • Yes • Not applicable DVT Prophylaxis? • Compression Stockings • SQ Heparin Is essential imaging displayed? • Yes • Not applicable Nurse verbally confirms with the team: • Name of the procedure • That instrument, sponge and needle counts are correct or not applicable • Post Pump ABX • Medication/Drips How the specimen is labeled: • Verify patient name • Number of specimens • Are there any equipment problems to be addressed? • No • Yes: __________________ Surgeon, Anesthesia Professional and Nurse • Review the key concerns for recovery and management of this patient • Patient • Procedure • Perfusion Temp • Prep Protocol • Site/Side • Position • Blood Born Path • Implants & Equip. SIGN (NURSING): ________________ SIGN (ANESTH): _________________ • SIGN (NURSING): ___________________ SIGN (SURG): _____________________ SIGN (SURG): _____________________

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