SIGN IN(nurse & anesthetist)

Circulating Nurse: Hello I’m ______________, how are you?

Patient: I am fine
Circulating Nurse: Could you please confirm name and date of birth?
Patient: _________; _____________ Circulating Nurse:
What procedure are you having done today?
Patient: Gallstones
Circulating Nurse: I need to check you have signed the consent form Patient: Yes, I
signed it already. Circulating Nurse: Is the site marked?
Anesthetist:not applicable
Circulating Nurse: Is the anesthesia machine and medication check complete?
Anesthetist: Yes, the anesthesia machine and medications are complete
Circulating Nurse: Is the pulse oximeter on the patient functioning?
Anesthetist: Yes Circulating Nurse: Do you have any known allergies?
Patient: No
Circulating Nurse: Does the patient have a difficult airway/ aspiration risk?
Anesthetist: Not anticipated
Circulating Nurse:Does the patient have a risk of blood loss?
Anesthetist: Minimal

TIME OUT(nurse, anesthetist, surgeon)

Circulating Nurse: All team members have to introduce themselves by name and
role
Anesthetist: _________________, consultant anesthetist
Surgeon: ____________________, consultant surgeon
Circulating nurse: _______________, circulating nurse
Scrub nurse: _________________, scrub nurse

Circulating Nurse: Please confirm the patient’s name, procedure, and where the
incision will be made Surgeon: (name of pt) for laparoscopic cholecystectomy, her
name tags has already been checked Circulating Nurse: Has antibiotic prophylaxis
been given within the last 60 minutes?
Anesthetist: 1.2 grams of augmentin is in the patient
Circulating Nurse: Are there any critical steps?
Surgeon: Possibility for a conversion to open surgery
Circulating Nurse: Are there specific requirements?
Surgeon: Laparoscopic cholecystectomy set has been checked already
Circulating Nurse: Any expected blood loss?
Surgeon: Minimal

Circulating Nurse: Any specific patient-anesthetic concerns? Anesthetist: None

C. Nurse: Has sterility of the instrumentation been confirmed? S. Nurse: Yes
C. Nurse: Are there any equipment issues or concerns?
S. Nurse: I’ve got the standard laparoscopic equipment, would you be requiring
anything extra?
Surgeon: Well we have open set on standby

C. Nurse: Is essential imaging displayed?

Anesthetist: not required
SIGN OUT(nurse, anesthetist, and surgeon)
C. Nurse: What’s the name of the procedure?
Surgeon: Laparoscopic cholecystectomy
C. Nurse: Are the instruments, swabs, and sharp counts are complete?
S. Nurse: Counts correct
C. Nurse: The specimen is labeled (name of pt), gallbladder Surgeon: Yes, that’s
correct
C. Nurse: Have there been any equipment problems?
S. Nurse: No
C: Nurse: Are there any key concerns for recovery?
Surgeon: No special key concerns