Before Patient Enters Room

South Carolina Ambulatory Surgery Checklist

Pre-Op

Before Patient Enters Room

Nurse and Anesthesia Provider review:
q Patient identification (name and DOB)
q Surgical site
q Surgical Procedure to be performed matches the consent
q The site has been marked
q Patient position
q Known allergies
q Patient weight
q Implants available in the OR
Correct type and size
q Essential imaging available
Nurse discusses:
q Risk of hypothermia - operation >1 h
Warmer in place
q Risk of venous thromboembolism
Boots and/or anticoagulants in place
q Does the patient need:
Foley
Tourniquet
Anesthesia Provider discusses:
q Anesthesia safety check is completed
q Type of anesthesia
q Changes in patient’s cardiac history
q Changes in patient’s respiratory history

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.

South Carolina Ambulatory Surgery Checklist

Pre-Op

Before Skin Incision

q Everyone please state your name and role.
Surgeon, Nurse, and Anesthesia Provider perform the Time Out:
q Patient’s name
Verify from consent and H&P:
q Surgical procedure to be performed
q Surgical Site
q Has antibiotic prophylaxis been given within the last 60 minutes, if indicated?

Briefing

Surgeon discusses:
q Any changes to operative plan and possible difficulties
Anesthesia Provider discusses:
q Anesthetic plan
q Airway or other concerns
Nursing team discusses:
q Any equipment issues or other concerns
q All medications correct and labeled
q Confirms correct implants
Surgeon states:
“Does anybody have any concerns? If you see something that concerns you during this case, please speak up.”

Before Patient Leaves Room

Nurse reviews with team:
q Instrument, sponge and needle counts are correct
q Name of the procedure performed
q Specimen labeling
Read back specimen labeling including patient’s name

Debriefing

Surgical Team Discusses:
q Equipment problems that need to be addressed
q Key concerns for patient recovery and management
q If anything could have been done to make this case safer or more efficient

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.