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Patient has confirmed: Identity Site Procedure Consent H & P Current (< 30d) Weight Re-Checked

Patient has confirmed: Identity Site Procedure Consent H & P Current (< 30d) Weight Re-Checked Anesthesia Safety Check completed (machine & meds) Pulse oximeter on patient and functioning Does patient have a known allergy? No Yes Drugs Latex Other:__________________

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Patient has confirmed: Identity Site Procedure Consent H & P Current (< 30d) Weight Re-Checked

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  1. Patient has confirmed: • Identity • Site • Procedure • Consent • H & P Current (< 30d) • Weight Re-Checked • Anesthesia Safety Check completed (machine & meds) • Pulse oximeter on patient and functioning Does patient have a known allergy? • No • Yes • Drugs • Latex • Other:__________________ Difficult Airway/Aspiration Risk? • No • Yes, & equipment/assistance available • Intravenous access and fluids planned • Warmer (blankets & fluids) in place Blood bank notified & Blood available? • No • Yes • Confirm all team members have introduced themselves by name and role • Surgeon, Anesthesia Professional, Perfusionist and Nurse verbally confirm: • Perfusion Strategy: Anesthesia Team Reviews: • Any patient-specific concerns? Nursing Team Reviews: • Equipment sterility confirmed? • Are there equipment/prostheses issues or any concerns? Nurse verbally confirms with the team: • Name of the procedure • That instrument, sponge and needle counts are correct or not applicable How the specimen is labeled: • Verify patient name • Number of specimens • Sent for appropriate tests • Are there any equipment problems to be addressed? • No • Yes: __________________ Surgeon, Anesthesia Professional and Nurse • Review the key concerns for post-op recovery and management of this patient • Blood products used • Blood products still available • Breaks in technique • Patient • Site • Procedure • Imaging Available & Reviewed • Transesophageal Echo (Tee) or Other Echo • Antifibrinolytics • Antibiotics Administered (within last 60 min) • Cannulation Sizes • Cannulae Sizes • Bypass Prime (blood vs. prime) • Targeted Core Temp • Use or Non-Use of DHCA, Selective Cerebral Perfusion • Ice on the head • Other Bypass Considerations (shunts, collaterals, AR, LV, venting, Cardioplegia, etc.) SIGN (NURSING): ________________ SIGN (ANESTH): _________________ • SIGN (NURSING): ___________________ SIGN (SURG): _____________________ SIGN (SURG): _____________________

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