PREPROCEDURE CHECK-IN

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