| Sign in | | Before induction of anesthesia | | __ | Patient has confirmed: - Identity
- Site
- Procedure
- Consent
| | __ | Site marked/not applicable | | __ | Anesthesia safety check completed | | __ | Pulse oximeter on patient and functioning | | Does patient have a: | | Known allergy? | | __ | No | | __ | Yes | | Difficult airway/aspiration risk? | | __ | No | | __ | Yes, and equipment/assistance available | | Risk of >500 mL blood loss (7 mL/kg in children)? | | __ | No | | __ | Yes, and adequate intravenous access and fluids planned | | | Time out | | Before skin incision | | __ | Confirm all team members have introduced themselves by name and role | | __ | Surgeon, anesthesia professional, and nurse verbally confirm | | Anticipated critical events | | __ | Surgeon reviews: What are the critical or unexpected steps, operative duration, anticipated blood loss? | | __ | Anesthesia team reviews: Are there 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 | | Is essential imaging displayed? | | __ | Yes | | __ | Not applicable | | | Sign out | | Before patient leaves operating room | | Nurse verbally confirms with the team: | | __ | The name of the procedure recorded | | __ | That instrument, sponge, and needle counts are correct (or not applicable) | | __ | How the specimen is labeled (including patient name) | | __ | Whether there are any equipment problems to be addressed | | __ | Surgeon, anesthesia professional, and nurse review the key concerns for recovery and management of this patient | |
