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?
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,,
© World Health Organization 2009. All rights reserved.

Page last reviewed April 2017
Page originally created April 2017
Internet Citation: Appendix D. Ambulatory Surgery Center Checklist Template - Implementation Guide. Content last reviewed April 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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