Appendix D. Ambulatory Surgery Center Checklist Template - Implementation Guide
Ambulatory Surgery Checklist - Preop
| Before Patient Enters Room |
| Nurse, Anesthesia Professional, and Patient Review: |___| Patient identification (name and date of birth) |___| Surgical site |___| Surgical procedure to be performed matches the consent form |___| Site is marked by individual performing the procedure |___| Patient position |___| Known allergies |___| Patient weight |___| History and physical |
| Nurse and Anesthesia Professional Discuss: |___| Implants available in the operating room - Correct type and size |___| Essential imaging available |___| Risk of hypothermia – operation longer than 1 hour - Warmer in place |___| Risk of venous thromboembolism - Compression boots and/or anticoagulants in place |___| Anesthesia safety check completed |___| Type of anesthesia |___| Anticipated airway and aspiration risk |___| Changes in patient's cardiac history |___| Changes in patient's respiratory history |
Ambulatory Surgery Checklist - Operating Room
| Before Skin Incision |
| Entire Surgical Team |___| Is everyone ready to perform the Timeout? |___| Please state your name and role. Surgeon, Nurse, and Anesthesia Professional perform the Timeout |___| Patient's name |___| Surgical procedure to be performed matches the consent |___| Surgical site |
| |___| Has antibiotic prophylaxis been given within the last 60 minutes, if indicated? |
| Briefing |
| Surgeon Shares: |___| Any changes to operative plan and possible difficulties Anesthesia Professional Shares: |___| Anesthetic plan |___| Airway and other concerns Circulating Nurse and Scrub Tech Share: |___| Equipment issues |___| Other concerns Circulating Nurse and Scrub Tech Confirm: |___| All medications are correct and labeled |___| Implant type and size |
| Surgeon States: "Does anybody have any concerns? If you see something that concerns you during this case, please speak up." |
| Before Patient Leaves Room/Debriefing |
| Nurse Reviews With Team: |___| Instrument, sponge and needle counts are correct |___| Name of the procedure performed |___| Specimen labeling - Read back specimen labeling including patient's name |
| Surgical Team Discusses: |___| Equipment problems that need to be addressed |___| Key concerns for patient recovery and management |___| If anything can be done to make the next case safer or more efficient |
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
Based on the WHO Surgical Safety Checklist,
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© World Health Organization 2009. All rights reserved.
