Hospital Auditors

Ward Endoscopy Date of Audit

No in Audit 1

Instructions: Possible answers provided - Please circle appropriate answer

Patient Chart No
Audit No 1 2 3 4 5
Pt Chart No
Procedure
Elective or Emergency Elective Elective Elective Elective Elective
Procedure Emergency Emergency Emergency Emergency Emergency
Type of sedation
LA GA Sed LA GA Sed LA GA Sed LA GA Sed LA GA Sed
Did the Circulation Nurse
sign that the safe site
surgery time out check
was completed? Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
Did Operator 1
(Consultant Surgeon,
Registrar etc) sign that
the safe site surgery time
out check was
completed?
Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
Did (Operator 2 -
Surgeon, anaesthetist
etc) sign that the safe site
surgery time out check
was completed?
Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
Comment

Page 1 of 9
Hospital Hospital Auditors
Ward Ward Endoscopy Date of Audit
No in Audit No in Audit 1

Instructions: Possible
Instructions:
answers
Possible
provided
answers
- Please
provided
circle-appropriate
Please circle
answer
appropriate answer
Patient Chart No
Audit No 6 7 8 9 10
Pt Chart No
Procedure
Elective or Emergency Elective Elective Elective Elective Elective
Procedure Emergency Emergency Emergency Emergency Emergency
Type of sedation
LA GA Sed LA GA Sed LA GA Sed LA GA Sed LA GA Sed
Did the Circulation Nurse
sign that the safe site
surgery time out check
was completed? Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
Did Operator 1
(Consultant Surgeon,
Registrar etc) sign that
the safe site surgery time
out check was
completed?
Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
Did (Operator 2 -
Surgeon, anaesthetist
etc) sign that the safe site
surgery time out check
was completed?
Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
Comment

Page 2 of 9
 Audit Tool

Safe Site Surgery

Hospital XYZ Auditor(s)
Ward ABC Date of Audit
No. in Audit 30 No. of Questions 1
Instruction: Click on cells to access drop down list of possible answers. Please enter total no of patients included in audit in to yellow box to enable automatic
calculation of

Patient Chart No
Audit No 1 2 3 4 5 6 7 8 9 10
1 Elective or Emergency Procedure Emergency
2 Type of sedation Sed
Procedure
3
Did the Circulation Nurse sign that the
safe site surgery time out check was
4 completed?
Did Operator 1 (Consultant Surgeon,
Registrar etc) sign that the safe site
surgery time out check was completed?
5
Did (Operator 2 - Surgeon, anaesthetist
etc) sign that the safe site surgery time
out check was completed?
6
 Audit Tool

Safe Site Surgery

Hospital XYZ Auditor(s) 0
Ward ABC Date of Audit 0
No. in Audit 30 No. of Questions 1

Patient Chart No
Audit No 11 12 13 14 15 16 17 18 19 20
1 Elective or Emergency Procedure
2 Type of sedation
Procedure
3
Did the Circulation Nurse sign that the
safe site surgery time out check was
4 completed?
Did Operator 1 (Consultant Surgeon,
Registrar etc) sign that the safe site
surgery time out check was completed?
5
Did (Operator 2 - Surgeon, anaesthetist
etc) sign that the safe site surgery time
out check was completed?
6
 Audit Tool

Safe Site Surgery

Hospital XYZ Auditor(s) 0
Ward ABC Date of Audit 0
No. in Audit 30 No. of Questions 1

Patient Chart No
Audit No 21 22 23 24 25 26 27 28 29 30
1 Elective or Emergency Procedure
2 Type of sedation
Procedure
3
Did the Circulation Nurse sign that the
safe site surgery time out check was
4 completed?
Did Operator 1 (Consultant Surgeon,
Registrar etc) sign that the safe site
surgery time out check was completed?
5
Did (Operator 2 - Surgeon, anaesthetist
etc) sign that the safe site surgery time
out check was completed?
6
 Audit Tool

Hospital
Ward
No. in Audit

Patient Chart No
Audit No
1 Elective or Emergency Procedure
2 Type of sedation
Procedure
3
Did the Circulation Nurse sign that the
safe site surgery time out check was
4 completed?
Did Operator 1 (Consultant Surgeon,
Registrar etc) sign that the safe site
surgery time out check was completed?
5
Did (Operator 2 - Surgeon, anaesthetist
etc) sign that the safe site surgery time
out check was completed?
6
 Results

Safe Site Surgery

Hospital XYZ
Ward ABC
Auditor(s) 0
Date of Audit 12/30/1899
No. in Audit 30 No. of Questions 1

Elective or Emergency Procedure

Frequency %
Elective 0 0.00%
Emergency 1 3.33%
Total 1 3.33%

Type of sedation
Frequency %
LA 0 0.00%
GA 0 0.00%
Sed 1 3.33%
Total 1 3.33%

Procedure
Frequency %
Colonoscopy 0 0.00%
OGD 0 0.00%
Sed 0 0.00%
Total 0 0.00%

Standards Yes No N/A Compliance

Did the Circulation Nurse sign that the safe site surgery
time out check was completed? 0 0 0 0.0

Did Operator 1 (Consultant Surgeon, Registrar etc) sign

that the safe site surgery time out check was completed? 0 0 0 0.0

Did (Operator 2 - Surgeon, anaesthetist etc) sign that the

safe site surgery time out check was completed? 0 0 0 0.0
Overall Compliance 0 0 0 0
 RECOMMENDATIONS

0
Hospital XYZ
Ward ABC
Auditor(s) 0
Date of Audit 30/12/1899
No. in Audit 30 No. of Questions 1

Recommendations arising from the audit: Responsibilty Date for Completion

4
 RECOMMENDATIONS

Completion