Policy Name:
Section:
Policy #:
Purpose
Safe Surgery Checklist
To establish protocol for safe surgery checklist
Approved Date
Reviewed Date
Revised Date
POLICY:
To ensure that all surgical procedures are performed in a safe manner as required by federal and state
regulations.
PROCEDURE:
Every patient’s medical record will have a Safety Surgery Checklist.
The pre-op RN will confirm patient identity, allergies, and the correct operative site with the patient
during the pre-op assessment. The pre-op nurse verifies procedure to be performed with operative
consent and marks the surgical site.
The surgeon will mark the surgical site on the patient using an indelible marker in collaboration with the
patient or the patient’s family member, prior to the patient entering the operating room. A site mark will
be made at or adjacent to the incision site.
If the patient is unable to participate in the site marking, the physician, in collaboration with a family
member (legal representative) or another licensed person will mark the site.
The operating room nurse will confirm the patient’s identity, allergies, and correct surgical location with
the patient, the consent, and the surgeon’s marking of the operative site prior to taking the patient to the
operating room.
Anesthesia provider performs machine and medication check and verifies pre-anesthesia assessment
performed to include assessment for difficult airway or aspiration risk.
Time out will be performed prior to incision. All team members will confirm patient’s identity, allergies,
correct procedure and site, and verify implant to be used. Surgical Tech verifies sterility has been
maintained, including chemical indictor results.
Before transfer to the recovery area, the Operating Room Nurse will verbally confirm the procedure
performed, completion of instrument, sponge and needle count. Any specimens are identified and labeled.
Patients Refusing Site Marking:
If the patient and/or family refuse the standard site marking process, the nursing staff will re-confirm and
re-educate the patient and family the reason and safety precautions in completing the site marking. This
explanation is to be documented in the patient’s medical record.
If the patient and/or family continue to refuse the site marking even after additional education, the
alternative for site (skin) marking will be applied, using the designated ankle band for purposes of
marking.
The arm band will be applied to the correct side for the procedure requiring a specific lateral location,
following the same site (skin) marking process, done by the physician.
The arm band will include patient name, date of birth and intended procedure.
The arm band will be removed in the post procedure recovery area.
Technically or Anatomically Impossible or Impractical to Mark Sites:
A defined, alternative process is in place for those patients where marking cannot easily be conducted
such as mucosal surfaces, minimal access procedures that intend to treat a lateralized internal organ
(either percutaneous or through a natural orifice such as teeth, urethral sites).
In lieu of marking the site with an indelible marker, the use of a band will be applied to the patient’s ankle
designating the surgical or procedural site using the same site (skin) marking process, done by the
physician.