Procedure Checklists: Role-Based Pack

Pre-procedure RN Checklist

• Confirm patient identity — 2 patient identifiers (name, DOB or MRN).
• Verify procedure & consent — confirm signed informed consent and the procedure matches the consent document.
• NPO & prep status — verify NPO time or other preparation orders completed.
• Medication reconciliation — confirm hold/continue instructions for anticoagulants, insulin, etc.
• Allergies & alerts — verify documented allergies and allergy band present.
• Vital signs and baseline assessment — record required baseline observations per local protocol.
• Special equipment or implants — confirm availability and labeling (if applicable).

Minimum documentation

• Patient identifiers used
• Consent present? (Yes/No) — Consent ID or scanned location
• NPO status and time
• Medications held/continued (list)
• Baseline vitals and assessment time

Escalation triggers

• Consent missing or incomplete — escalate to attending/consenter immediately.
• Uncontrolled bleeding risk, fever, or abnormal vitals — consult physician and postpone if required by policy.
• Patient refuses or is confused about procedure — pause and escalate to provider for re-consent/clarification.

Procedure Tech / Surgical/Procedure Room Checklist

• Equipment check — verify all devices, scopes, and instruments are present and functioning.
• Sterilization & trays — confirm sterilization indicators and integrity of sterile packaging.
• Counts & consumables — initial instrument/needle/sponges counts (if applicable) and expected count method.
• Implant/device tracking — confirm lot numbers, expiry dates, and labeling captured.
• Adjunct supplies — suction, cautery, tubing, dressings available.
• Room readiness — position patient, lighting, imaging access, suction/oxygen checked.

Minimum documentation

• Equipment tested (list major items)
• Sterilization indicator results
• Initial count recorded (Yes/No) — count sheet location
• Implant serial/lot numbers

Escalation triggers

• Broken or malfunctioning critical equipment — stop and escalate; reschedule if no immediate replacement.
• Failed sterilization indicator — notify infection prevention and physician; do not use affected items.
• Missing implant or mismatched implant labeling — halt and verify inventory and orders.

Physician / Proceduralist Checklist

• Time-out / team brief — lead a verbal time-out using three identifiers: patient, procedure/site, planned critical steps.
• Mark site — where applicable, site marked and agreed by team and patient if awake.
• Critical steps & contingencies — verbally confirm anticipated critical steps and contingency plans (e.g., expected blood loss, airway concerns).
• Antibiotic & prophylaxis orders — confirm timing and administration if required.
• Patient positioning & access — confirm position is safe and access secured.
• Confirm monitoring — ensure required monitoring (ECG, SpO2, capnography) is in place.

Minimum documentation

• Time-out completed (time and initials)
• Procedure start time
• Antibiotic given (name, dose, time) if applicable
• Major deviations or unplanned events

Escalation triggers

• Unclear time-out or disagreement about site/procedure — stop and resolve before proceeding.
• Unexpected deterioration in patient status — activate emergency response and follow local escalation.
• Impossible to maintain sterile field — pause and correct before continuing.

Post-procedure Handover Checklist (To PACU / Ward / Next Care Team)

• Immediate status — hemodynamics, airway, oxygen requirement, pain level.
• Procedure summary — brief description, estimated blood loss, implants placed.
• Remaining tasks — dressings, drains, imaging pending, antibiotics ordered.
• Outstanding counts — final instrument/sponges count confirmed.
• Escalation instructions — clear thresholds for notifying the team (vital signs, bleeding, pain uncontrolled).
• Follow-up & documentation — planned imaging, labs, and first post-op checks with timing.

Minimum documentation

• Procedure end time
• Final count confirmed (Yes/No) and signature
• Estimated blood loss
• Implants documented
• Handover recipient name and time

Escalation triggers

• Final count discrepancy — immediate search and imaging per policy; notify surgeon and safety officer.
• Uncontrolled bleeding or airway compromise — call emergency response and inform receiving team immediately.
• Unexpected device or implant issue — notify manufacturer rep and clinical engineering if relevant.

Customization & Implementation Notes

These checklists are templates. Before deploying locally:

• Map each checklist item to your policies, roles, and clinical documentation fields (EHR flowsheets, scanned consent location).
• Decide whether to use paper, laminated cards, or digital forms. Digital versions should save timestamps, user IDs, and version numbers.
• Train teams on the purpose of the checklist: not a box-checking exercise but a coordination and safety tool.
• Version control: add a visible version/date on each checklist so staff know they are using the latest protocol.
• Audit periodically (e.g., weekly or monthly sampling) for compliance and effectiveness; capture near-misses as learning events.

Suggested fields if converting to a digital InteractiveForm

• ChecklistID, Role, Patient MRN, Encounter ID, Timestamp, UserID
• Yes/No fields for critical items (consent present, final count OK)
• Short text fields for free-text notes (e.g., implant lot numbers, deviations)
• Escalation flag (yes/no) and escalation notes (who was notified and when)

Training & Measurement

Track a few simple indicators to measure impact: checklist completion rate, timeouts performed, count discrepancies, and procedure-related adverse events. Use collected data to refine the checklists and escalate system issues.