Appendix E. Endoscopy Checklist Template - Implementation Guide

Endoscopy Safety Checklist - Preprocedure Area/Procedure Room

Before Patient Enters Room
Nurse, Anesthesia Professional, and Patient Review:
|___| Patient identification (name and date of birth)
|___| Procedure to be performed matches the consent
|___| Known allergies
|___| Patient height, weight, body mass index
|___| History and physical
Anesthesia Professional and Nurse Discuss:
|___| Anesthesia safety check is completed
|___| Type of anesthesia
|___| Anticipated airway and aspiration risk
|___| Patient-specific concerns
Before Procedure Begins
Team Introductions
|___| Please state your name and role
Proceduralist Shares:
|___| Any changes to the plan and possible difficulties
|___| Necessary equipment/devices are available

Anesthesia Professional Shares:
|___| Anesthetic plan
|___| Airway and other concerns

Nursing Team Shares:
|___| Any equipment issues
|___| Other concerns

Nursing Team Confirms:
             - All medications correct and labeled

|___| Is everyone ready to perform the timeout?
The Team Performs The Timeout
|___| Patient's name
|___| Procedure to be performed matches the consent form
|___| Procedure site
Proceduralist 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:
|___| Name of the procedure performed
|___| Identify/confirm patient restriction for diet or activity in recovery interval
|___| Specimen labeling
             - Read back specimen labeling including patient's name
Team Discusses:
|___| Equipment problems that need to be addressed
|___| Key concerns for patient recovery and management
|___| Whether 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 May 2017
Page originally created April 2017
Internet Citation: Appendix E. Endoscopy Checklist Template - Implementation Guide. Content last reviewed May 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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