PREPROCEDURE SIGN-IN TIME-OUT SIGN-OUT

CHECK-IN
In Holding Area Before Induction of Before Skin Incision Before the Patient Leaves the
Anesthesia Operating Room
Patient/patient RN and anesthesia care Initiated by designated team RN confirms:
representative provider confirm: member
actively confirms with All other activities to be suspended
Registered Nurse (RN): (unless a life-threatening emergency)
Identity Yes Confirmation of: identity, Introduction of team members Yes Name of operative procedure
Procedure and procedure procedure, procedure site and All: Completion of sponge, sharp, and
site Yes consent(s) Yes Confirmation of the following: identity, instrument counts Yes N/A
Consent(s) Yes Site marked Yes N/A procedure, incision site, consent(s) Specimens identified and labeled
Site marked Yes N/A by person performing the Yes Yes N/A
by person performing the procedure Site is marked and visible Yes Any equipment problems to be
procedure N/A addressed? Yes N/A
Patient allergies Yes N/A
RN confirms presence of: Relevant images properly labeled and
History and physical Yes Difficult airway or aspiration displayed Yes N/A To all team members:
risk? What are the key concerns for
Preanesthesia assessment No Any equipment concerns? recovery and management of this
Yes Yes (preparation confirmed) patient?
Anticipated Critical Events _________________________________
Diagnostic and radiologic test Risk of blood loss (> 500 ml) Surgeon: _________________________________
results Yes N/A Yes N/A States the following: _________________________________
# of units available ______ critical or nonroutine steps _________________________________
Blood products case duration _________________________________
Yes N/A Anesthesia safety check anticipated blood loss _________________________________
completed _________________________________
Yes Anesthesia Provider: _________________________________
Any special equipment,
devices, implants Antibiotic prophylaxis within one hour
Briefing: April 2010
Yes N/A All members of the team have before incision Yes N/A
Include in Preprocedure discussed care plan and Additional concerns?
check-in as per addressed concerns
institutional custom: Yes Scrub and circulating nurse:
Beta blocker medication Sterilization indicators have been
given (SCIP) Yes confirmed
N/A Venous Additional concerns?
thromboembolism
prophylaxis ordered
(SCIP) Yes N/A
Normothermia measures