| Before induction of Anesthesia |
Has the patient confirmed his/her identity, site, procedure, and consent?
Is the site marked?
Is the anaesthesia machine and medication check complete?
Is the pulse oximeter on the patient and functioning?
Does the patient have a:
Before skin incision
| Anticipated Critical Events |
What are the critical or non-routine steps?
How long will the case take?
What is the anticipated blood loss?
Are there any patient specific concerns?
To Nursing Team:
Has sterility (including indicator results) been confirmed?
Are there equipment issues or any concerns?
Is essential imaging displayed?
| Before patient leaves operating room |
Nurse Verbally Confirms:
The name of the procedure?
Completion of instrument, sponge and needle counts
Specimen labelling (read specimen labels aloud, including patient name)
Whether there are any equipment problems to be addressed
To Surgeon, Anaesthetist and Nurse:
Are there any key concerns for recovery and management of this patient?
| Completion |
Surgeons Full Name:
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