| Item 1 - Patient name checked using two identifiers □ Yes □ No (Inform) |
Rewritten |
Confirm patient’s name, date of birth, weight and height □ Yes □ No (Inform) |
| Item 2 - Confirmation of the procedure to be performed □ Yes □ No (Confirm before proceeding) |
Valid |
Confirmation of the procedure to be performed □ Yes □ No (Confirm before proceeding) |
| Item 3 - Delimited surgical site □ Yes □ No (Confirm) □ Not applicable |
Excluded |
Excluded |
| Item 4 - Checked consent form (Surgical, Anesthetic and blood components) □ Yes □ No (Confirm before proceeding) |
Valid |
Checked consent form (Surgical, Anesthetic and blood components) □ Yes □ No (Confirm before proceeding) |
| Item 5 - Preoperative preparation: fasting time, bath and hair removal □ Yes □ No (Inform) |
Valid, not supported rewritten |
Preoperative preparation: fasting time, bath and hair removal □ Yes □ No (Inform) |
| Item 6 - Presence of known allergy □ Yes (Inform) □ No |
Valid, not supported rewritten |
Presence of known allergy □ Yes (Which? ________) □ No |
| Item 7 - Assembly of the operating room (OR) according to the scheduled procedure? □ Yes □ No (Correct before proceeding) |
Valid |
Assembly of the operating room (OR) according to the scheduled procedure? □ Yes □ No (Correct before proceeding) |
| Item 8 - Surgical materials with correct identification of sterilization □ Yes □ No (To correct before proceeding) |
Valid |
Surgical materials with correct identification of sterilization □ Yes □ No (To correct before proceeding) |
| Item 9 - Operating room (OR) equipment available and tested? □ Yes □ No (Test before proceeding) |
Valid |
Operating room (OR) equipment available and tested? □ Yes □ No (Test before proceeding) |
| Item 10 -Implants required? □ Yes □ No □ Standby |
Rewritten |
Implants required? □ Yes (Which? _____) □ No □ Stand by |
| Item 11- In case of organ transplantation, check donor/recipient ABO compatibility □ Yes □ No (Confirm before proceeding) □ Not applicable |
Rewritten |
Donor/Recipient ABO Compatibility Check □ Yes □ No (Confirm before proceeding) □ Not applicable |
| Item 12 - Availability of blood supply? □ Yes (Which and How much) □ No (Confirm before proceeding) □ Not applicable |
Valid |
Availability of blood supply? □ Yes (Which and How much) □ No (Confirm before proceeding) □ Not applicable |
| Item 13 -Heating system required? □ Yes □ No |
Rewritten/ Repositioned |
Patient warming system required? □ Yes □ No |
| Item 14 - Risk of difficult airway or Bronchoaspiration? □ Yes (There is available equipment) □ No |
Valid |
Risk of difficult airway or Bronchoaspiration? □ Yes (There is available equipment) □ No |
| Item 15 - ASA rating □ Yes □ No (Confirm before proceeding) |
Valid |
ASA rating □ Yes □ No (Confirm before proceeding) |
| Item 16 - Anesthetic safety check: Anesthesia device, Patient monitoring, Tube position, Drug identification □ Yes □ No (Confirm before proceeding) |
Rewritten |
Anesthetic safety check: Anesthesia device Patient monitoring and Drug identification □ Yes □ No (Confirm before proceeding) |
| Item 17 - Expected anesthetic risks for the patient? □ Yes (Inform) □ No |
Excluded |
Excluded |
| Item 18 - Midline incision? □ Yes □ No (Inform laterality) Site: _________ |
Valid, not supported, rewritten |
Midline incision? □ Yes □ No (Inform laterality) Site: _________ |
| Item 19 - Identification of MRSA (methicillin-resistant Staphylococcus aureus) □ Yes (Inform) □ No |
Valid, not supported rewritten |
Identification of MRSA (methicillin-resistant Staphylococcus aureus) □ Yes (Inform) □ No |
| Item 20 - Names and professions □ Yes □ No (Confirm before proceeding) |
Repositioned |
Names and Professions □ Yes □ No (Confirm before proceeding) |
| Item 21 - Patient name, weight, height and procedure □ Yes □ No (Confirm before proceeding) |
Excluded; Weight and height included in item 1 |
Excluded |
| Item 22 - Surgical position and positioners to minimize risk associated to patient positioning □ Yes □ No (Check before proceeding) |
Repositioned |
Surgical position and positioners to minimize risk associated to patient positioning □ Yes □ No (Check before proceeding) |
| Item 23 - Any hazards identified? □ Yes (Inform) □ No |
Rewritten / repositioned |
Any unsafe situation before starting the procedure? □ Yes (Inform) □ No |
| Item 24 - Duration of the procedure Time: _____________ |
Repositioned |
Duration of the procedure Time: _____________ |
| Item 25 - Preventive measures against surgical site infection □ Yes □ No (Prepare before proceeding) |
Valid |
Preventive measures against surgical site infection □ Yes □ No (Prepare before proceeding) |
| Item 26 - Predictable critical moments during the procedure □ Yes (Clarify before proceeding) □ No |
Repositioned |
Predictable critical moments during the procedure? □ Yes (Clarify before proceeding) □ No |
| Item 27 - Imaging exams viewed? □ Yes □ No (Make available before proceeding) |
Rewritten / repositioned |
Exams viewed? □ Yes □ No (View before proceeding) |
| Item 28 - Risk of blood loss >500ml (7ml/kg in children) □ Yes □ No |
Repositioned |
Risk of blood loss > 500ml (7ml/kg in children) □ Yes □ No |
| Item 29 - Patient risk classification Risk: _______________ |
Repositioned |
Patient risk classification Risk: ___________ |
| Item 30 - Sterilization of instruments confirmed by the surgical technologist? □ Yes □ No (Confirm before proceeding) |
Repositioned |
Sterilization of instruments confirmed by the surgical technologist? □ Yes □ No (Confirm before proceeding) |
| Item 31 - Count of instruments, needles, compresses and gauzes □ Yes □ No (Confirm before proceeding) |
Valid, not supported repositioning |
Count of instruments, needles, compresses and gauzes □ Yes □ No (Confirm before proceeding) |
| Item 32 - Availability of cannulae? □ Yes (Size _________) □ No (Inform) |
Valid, not Supported repositioning |
Availability of cannulae? □ Yes (Size _________) □ No (Inform) |
| Item 33 - Temperature to be reached? TºC _________ |
Rewritten / repositioned |
Body temperature to be reached? TºC ________________ |
| Item 34 - Deep hypothermic circulatory arrest or head with ice required? □ Yes □ No |
Rewritten / repositioned |
Circulatory arrest with deep hypothermia and cerebral Hypothermia required? □ Yes □ No |
| Item 35 - Myocardial protection solution required? □ Yes □ No |
Repositioned and Word solution removed |
Myocardial Protection Solution required? □ Yes □ No |
| Item 36 - Is the air sensor working? □ Yes □ No (Inform) |
Repositioned |
Is the air sensor working? □ Yes □ No (Inform) |
| Item 37 -Activated Clotting Time (ACT) checked? □ Yes □ No (Inform) |
Repositioned |
Activated clotting time (ACT) checked? □ Yes □ No (Inform) |
| Item 38 - Verbalization of the amount of heparin to be administered? □ Yes □ No (Inform) |
Valid |
Verbalization of the amount of heparin to be administered? □ Yes □ No (inform) |
| Item 39 - Amount of heparin to be administered □ Yes □ No (Confirm before proceeding) |
Rewritten / repositioned |
Heparin administered? □ Yes (Amount: _______) □ No (Confirm before proceeding) |
| Item 40 - Prophylactic antibiotic administered 60 minutes before surgical incision? □ Yes □ No (Inform) □ Not applicable |
Valid, included “Which” |
Prophylactic antibiotic administered 60 minutes before surgical incision? □ Yes (Which: _______) □ No (Inform) □ Not applicable |
| Item 41 - Plan for extra dose of prophylactic antibiotic? □ Yes □ Not applicable |
Valid |
Plan for extra dose of prophylactic antibiotic? □ Yes □ Not applicable |
| Item 42 -Special gas required? (nitric oxide, nitrogen, carbon dioxide) □ Yes □ Not applicable |
Repositioned |
Special gas required? (nitric oxide, nitrogen, carbon dioxide) □ Yes □ Not applicable |
| Item 43 - Procedure name change □ Yes (Inform) □ No |
Valid |
Procedure name change □ Yes (Inform) □ No |
| Item 44 - Recount of instruments, needles, compresses and gauzes □ Yes (Inform) □ No (Correct before proceeding) |
Valid |
Recount of instruments, needles, compresses and gauzes □ Yes (Inform) □ No (Correct before proceeding) |
| Item 45 - Biopsies identified? □ Yes □ Not applicable |
Valid |
Biopsies identified? □ Yes □ Not applicable |
| Item 46 - Any equipment issues that need to be resolved? □ Yes (Inform) □ No |
Valid |
Any equipment issues that need to be resolved? □ Yes (Inform) □ No |
| Item 47 - Sera and drugs identified? □ Yes □ No (Identify before proceeding) |
Rewritten |
Solutions and drugs identified? □ Yes □ No (Identify before proceeding) |
| Item 48 - Evidence of an adverse event? □ Yes (Inform) □ No |
Valid |
Evidence of an adverse event? □ Yes (Inform) □ No |
| Item 49 - Recommendations for the patient’s postoperative period □ Yes (Inform) □ No |
Valid |
Recommendations for the patient’s postoperative period □ Yes (Inform) □ No |
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Source: Researchdata, 2021.