NURSING ADMINISTRATION

UNIT SPECIFIC SKILLS COMPETENCY

ENSURE SAFE SURGERY
OPERATING ROOM
STAFF NAME: __________________________
EMPLOYEE NO: ________________________
POSITION/DESIGNATION: ________________
DATE OF HIRE: _____________________________
RATING SCALE INDICATOR
1 Poor in Unable to demonstrate or perform.
knowledge/skill/behavior
2 Fair in Demonstrate/performs safely with close guidance and supervision.
knowledge/skill/behavior
3 Satisfactory in Demonstrate adequate knowledge/skills. Able to perform with
knowledge/skill/behavior minimal guidance/supervision.
4 Good in Performs independently and safely without guidance and/or
knowledge/skill/behavior supervision.
5 Excellent in Consistently performs independently and safely without guidance
knowledge/skill/behavior and/or supervision. Able to instruct, teach and mentor new nurses.

PERFORMANCE CRITERIA Date: Date:

NO (Ensuring correct site, procedure, patient and surgery is performed Rating Rating
prior to the invasive or surgical procedure)
1 CORRECT SITE *
1.1 Surgical site mark done by the doctor performing the procedure.
1.2 Mark with an arrow (↓) by the person who will perform the surgery.
1.3 Ensure to include the patient in the marking process.
2 CORRECT PROCEDURE *
2.1 Verify the procedure with valid written consent.
3 CORRECT PATIENT *
3.1 Correct patient identification using two identifiers (full name and
medical record no.
4 PERFORM TIME OUT – BEFORE SKIN INCISION/PUNCTURE
4.1 Immediately before starting the procedure, the nurse-in charge
must call for time out.
4.2 All surgical team members must participate and be attentive.
4.3 The following standard information should be addressed:

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 4.3. Correct patient identification
1
4.3. Correct side and site
2
4.3. Agreement of procedure to be done
3
4.3. Confirmation that the verification process has been completed
4
5 COMPLETE INTRA-OPERATIVE RECORDS
5.1 Documented in the time out section of the surgical records.
Total rating
Competency level (%)
Mentor Signature
Mentor name
Mentor position

Reference:

COMPETENCY DESCRIPTION
LEVEL
> 80 % Competent, able to perform without supervision.
51 – 79 % Need supervision, required reassessment after 2 weeks
< 50 % Required coaching and supervision, reassessment after 4 weeks

MENTOR COMMENT:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

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