Appendix I. Checklist Observation Tool and FAQs - Implementation Guide

Why Should We Use This Tool?

Monitoring checklist use is an extremely important part of this project. Performing observations can often reveal weaknesses in checklist performance that may otherwise go unnoticed. This tool allows you to collect information regarding the processes performed in the operating room or procedure room in order to improve surgical outcomes.

How Should This Tool Be Used?

This tool should be used to assess current checklist practice in your facility.

  • The tool is made up of three separate observation tools corresponding to each part of the checklist:
    • Pre-op Briefing Before the Patient is Sedated
    • Before the Procedure is Started
    • Before the Patient Leaves the Room
  • Each individual observation tool can be used on its own in three separate cases, or the tools can be used all together in one case to watch all parts of the checklist discussion.
  • Tips for how to use the tool
    • If possible, you should fill out the tool during the case. If this is not possible, you can fill it out immediately afterward.
    • Avoid writing down personal identifiers on the tool.

How Many Cases Should We Observe?

  • To best understand how the checklist is used in your facility, observe as many teams as possible.

Who Should Complete This Tool?

  • Ideally, the person completing the tool should not be part of the team being observed. This could be your facility lead or someone dedicated to quality improvement.

How Should We Select The Cases To Observe?

  • Observe a variety of teams in your facility. We recommend that you watch teams at different times of the day and on different days of the week.

What Do We Do With The Completed Observation Tools?

  • Look for patterns to identify areas in which the team did well and possible areas for improvement. Patterns can help you identify your next intervention for improvement.

Preoperative Briefing Before the Patient Is Sedated, Observation Tool

Date: ______________
        (mm/dd/yyyy)

Step 1: Discussion Items
Please place a check by each item the team discussed during the preoperative briefing.

|___| Patient identification (name and date of birth)
|___| Surgical site
|___| Surgical procedure to be performed matches consent form
|___| Site marked
|___| Patient position
|___| Known allergies
|___| Patient weight
|___| Implants available in the operating room
|___| Essential imaging available
|___| Risk of hypothermia if the operation is longer than 1 hour
|___| Risk of venous thromboembolism
|___| Anesthesia safety check is completed
|___| Type of anesthesia
|___| Anticipated airway and aspiration risk
|___| Changes in patient's cardiac history
|___| Changes in patient's respiratory history

Step 2: Checklist Use Questions
After the discussion, please answer the following questions about how the checklist was used.

Did the circulating nurse discuss all items when at least one other care provider was present?

|___| Yes          |___| Some, not all          |___| No

Was the patient and/or family actively engaged in this discussion?

|___| Yes          |___| Some, not all          |___| No          |___| N/A

Were the checklist items done from memory?

|___| Yes          |___| No

Did each team member who was present say something?

|___| Yes          |___| Some, not all          |___| None

Could the team have performed this section of the checklist better?

|___| Yes          |___| No

Before the Procedure Is Started, Observation Tool

Date: ______________
         (mm/dd/yyyy)

Step 1: Discussion Items
Please place a check by each item the team discussed during the preoperative briefing.

|___| Patient's name
|___| Surgical procedure to be performed
|___| Surgical site
|___| Antibiotic prophylaxis been given within 60 minutes of the start of the case if applicable
|___| Any changes to operative plan and possible difficulties
|___| Anesthetic plan
|___| Airway
|___| Anesthesia concerns
|___| All medications are correct and labeled
|___| Implant type and size
|___| Circulating nurse concerns
|___| Equipment availability or issues
|___| Scrub technician concerns
|___| "Does anybody have any other concerns? If you see something that concerns you during this case, please speak up."

Step 2: Checklist Use Questions
After the discussion, please answer the following questions about how the checklist was used.

Did someone in the room ensure everyone was ready to perform the checklist before starting the discussion?

|___| Yes          |___| Somewhat          |___| No

Did everyone in the room come to a "hard stop" for the briefing?

|___| Yes          |___| Some, not all          |___| No

Did every person in the room introduce themselves?

|___| Yes          |___| Some, not all          |___| None

Were the checklist items done from memory?

|___| Yes          |___| No

Did each team member say something?

|___| Yes          |___| Some, not all          |___| No

Could the team have performed this section of the checklist better?

|___| Yes          |___| No

Before the Patient Leaves the Room, Debriefing Observation Tool

Date: ______________
         (mm/dd/yyyy)

Step 1: Discussion Items
Please place a check by each item the team discussed during the debriefing.

|___| Instrument, sponge, and needle counts are correct
|___| Name of the procedure performed
|___| Specimen labeling
|___| Equipment problems to be addressed
|___| Key concerns for patient recovery and management

Step 2: Checklist Use Questions
After the discussion, please answer the following questions about how the checklist was used.

Did someone in the room ensure everyone was ready to perform the debriefing before starting the discussion?

|___| Yes          |___| Somewhat          |___| No

If there was a specimen still in the room, did a team member read back the label from the container during the debriefing discussion?

|___| Yes          |___| No          |___| N/A

Were the checklist items done from memory?

|___| Yes          |___| No

Was every team member paying attention to the discussion?

|___| Yes          |___| Some, not all          |___| No

Was the surgeon/proceduralist in the room, when the debriefing took place?

|___| Yes          |___| No

Could the team have performed this section of the checklist better?

|___| Yes          |___| No

Page last reviewed May 2017
Page originally created April 2017
Internet Citation: Appendix I. Checklist Observation Tool and FAQs - Implementation Guide. Content last reviewed May 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-i.html
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