Ensuring Correct Surgery and Invasive Procedures Pre-Training Questionnaire

1. Ensuring Correct Surgery and Invasive Procedures Pre-Training Questionnaire Rank your confidence level regarding each of the following statements using scale below: Not confident at all < 1-------------2--------------3--------------4-------------5 > Completely confident I am confident in my understanding of . . . the definition of a surgical or non-surgical invasive procedure . . . . . . . . . 1 2 3 4 5 the use of a checklist prior to the start of an invasive procedure . . . . . . . .1 2 3 4 5 the system factors that contribute to incorrect procedures . . . . . . . . . . . 1 2 3 4 5 “speaking up” when something does not seem quite right . . . . . . . . . . . . 1 2 3 4 5 the actions to be taken when a team member is not able or refuses to follow the steps to ensure correct site surgery and invasive procedures . 1 2 3 4 5 6. the Ensuring Correct Surgery and Invasive Procedure Directive as applied in special circumstances (e.g. endoscopy) . . . . . . . . . . . . . . . . . 1 2 3 4 5 7. when the time-out process occurs and who must participate . . . . . . . . . 1 2 3 4 5 8. the key components of marking the procedure site . . . . . . . . . . . . . . . . . .. 1 2 3 4 5 9. the important elements of proper patient identification . . . . . . . . . . . . . 1 2 3 4 5 10. the correct method for reviewing imaging studies prior to commencing an operation or invasive procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5

2. Ensuring Correct Surgery and Invasive Procedures Observational Checklist Facility _________ Date________ Time Block_______Team_______ Rater _______