Surgical Safety Checklist at University of Miyazaki Hospital

ID: Patient name:



Enter before (at operating room entrance)

At the entrance of operating room

□Patient identification

□Document verification

□Confirmation of surgical site

□Order of prevention of deep vein thrombosis

In the operating room

□Patient confirmation by attending doctor with personal data assistance

□Confirmation of surgical site (preoperative marking) by attending doctor

□Allergy confirmation

Reporting for anesthesiologist

□Confirmation of preoperative orders

Observing items by operating room nurse

Back abnormality □absence □presence ( )

Limitation of joint range of motion □absence □presence ( )

Skin abnormality □absence □presence ( )

□Not applicable

(Abridgement of checklist due to emergency operation)

※Leave to record the abridged items

Before Skin incision (Time out)

□Self-introduction of members

□Recognition of patient name, surgical site by doctors

□Scheduled operating time

□Predicted blood loss (much more than usual amounts, etc.?)

□Important matters in surgery

□Timing of antibiotics

□Importance in anesthesia

□Continuous analgesia by Patient-Controlled Analgesia (PCA) (necessary, unnecessary)

□Duration of PCA

□The prohibition of steroid, Anticoagulant, dialysis intervention, and etc. during the operation

□Problem lists

□Preparation of required materials and equipments

Time out time ( : )

Time out members: Operator: ( ) Anesthesiologist: ( )

Attending doctor: ( ) Scrub nurse: ( )

Circulating nurse: ( )

□Not applicable (ultra-emergency operation)

Leaving before

□Confirmation of surgical procedure, position of drain

□Count of equipments Scrub nurse: ( ) Circulating nurse: ( )

Numbers of used equipments: Set ( ) Single ( )

Numbers of returned equipments: Set ( ) Single ( )

□Count of gauze □Not applicable Scrub nurse: ( ) Circulating nurse:( )