SAFETY GUIDELINES AND PROCEDURES IN THE OPERATING ROOM

DRESS CODE - SURGICAL ATTIRE 1. All persons who enter the semi restricted and restricted areas of the surgical suite should be in hospital laundered surgical attire intended for use only within the surgical suite 2. All possible head and facial hair, including sideburns and neckline, should be covered when in the surgical suite. 3. All persons entering an operating room should wear a mask. 4. All personnel entering the suite should have all jewelry confined or removed. Watches and plain wedding bands are acceptable. Earrings must be covered by the scrub cap. 5. Nail polish and artificial nails should not be worn within the suite. 6. Protective barriers (gloves, masks, protective eyewear, and face shields) are provided by the hospital and should be utilized to reduce the risk of exposure to potentially infective agents. 7. Shoes should be dedicated to the OR and shoe covers are not required. If shoe covers are necessary, the wearer should remove them before leaving the operating room to avoid tracking blood and debris through the department.

SURGICAL HAND SCRUB 1. A five (5) minute anatomical timed scrub will be used for all surgical hand scrubs. 2. Fingernails must be free of polish/enamel and of medium length. No jewelry is permitted on the hands and arms while performing as a member of the surgical team. 3. **Remember to put your mask on prior to starting you scrub. ** 4. Wash hands and arms with solution to 2 inches above the elbow. 5. Clean fingernails with file. Take sterile brush in right hand. Wet brush with water and soap. Scrub fingernails of left hand. 6. Start scrubbing fingers of left hand, one at a time, treating each finger as four-sided; palm, knuckles, and back of hand. Repeat with right hand. 7. Scrub right wrist and continue up arm to 2 inches above elbow. Repeat with left arm. Discard brush. Rinse both hands and arms under running water keeping hands above level of elbow so that water runs off the elbows and not the hands.

Operating Room Safety ProceduresMost injuries sustained by hospital employees occurring in the operating rooms (ORs). Because of sharp objects such as needles and scalpels, as well as other potentially dangerous medical devices, there are important safety rules and regulations to follow while in the OR. These procedures not only improve safety for employees, but promote a clean workplace, which in turn facilitates a better, safer experience for patients.

Needles and Sharp Objectso

Injury by needles or other sharp objects account for the majority of accidents in operating rooms. These can be avoided by following these safety procedures: Always use the safe zone while performing surgical procedures; make sure there is a strict account of all sharp objects used in a procedure; dispose of any needles or scalpels in the sharps container after they have been used.

Particle Releaseo

During certain procedures, particulates can form a hazard of their own in the operating room. The release of these particulates can create infection. By using suction near the point of particulate generation, much of these airborne particles can be eliminated. It also is advisable to wear regulation goggles and a respirator while performing such operations.

Anesthetic Gaseso

Anesthetic gases released into the operating room environment can have a serious effect on technicians, doctors and nurses working in the OR. These gases can cause reflexes to slow and mental processes to dull. The anesthesiologist should ensure this does not happen by checking all connections for leaks, keeping the equipment checked and serviced and making sure the scrubber has enough room for the gas to be used.

Electrical Shocko

Electrical shock in the OR is rare, but safety procedures should be in place to prevent it from happening. Shocks usually occur because of faulty equipment. Those using electrical equipment should unplug the equipment while holding the plug rather than the cord. If electrical shock does occur, the equipment should be removed from the OR immediately for repair.

General Safetyy y y y yApply good body mechanics at all times when transferring patients.

Operating room beds and gurneys will be locked before patient transfer.

Operating safety belts will be used for all patients.

Never disconnect or connect electrical equipment with wet or moist hands.

Discard all needles, razors, scalpel blades and broken glass into special identified containers.

GENERAL SAFETY PROCEDURES1. The patient is the center of the sterile field. 2. Only sterile items are used within the sterile field. A. Examples of items used. B. How do we know they are sterile? (Wrapping, label, storage) 3. Sterile persons are gowned and gloved. A. Keep hands at waist level and in sight at all times. B. Keep hands away from the face. C. Never fold hands under arms. D. Gowns are considered sterile in front from chest to level of sterile field, and the sleeves from above the elbow to cuffs. Gloves are sterile. E. Sit only if sitting for entire procedure. 4. Tables are sterile only at table level. A. Anything over the edge is considered unsterile, such as a suture or the table drape. B. Use non-perforating device to secure tubing and cords to prevent them from sliding to the floor. 5. Sterile persons touch only sterile items or areas; unsterile persons touch only unsterile items or areas. A. Sterile team members maintain contact with sterile field by wearing gloves and gowns.

B. Supplies are brought to sterile team members by the circulator, who opens wrappers on sterile packages. The circulator ensures a sterile transfer to the sterile field. Only sterile items touch sterile surfaces. 6. Unsterile persons avoid reaching over sterile field; sterile persons avoid leaning over unsterile area. A. Scrub person sets basins to be filled at edge of table to fill them. B. Circulator pours with lip only over basin edge. C. Scrub person drapes an unsterile table toward self first to avoid leaning over an unsterile area. Cuff drapes over gloved hands. D. Scrub person stands back from the unsterile table when draping it to avoid leaning over an unsterile area. 7. Edges of anything that encloses sterile contents are considered unsterile. A. When opening sterile packages, open away from you first. Secure flaps so they do not dangle. B. The wrapper is considered sterile to within one inch of the wrapper. C. In peel-open packages, the edges where glued, are not considered sterile. 8. Sterile field is created as close as possible to time of use. A. Covering sterile tables is not recommended. 9. Sterile areas are continuously kept in view. A. Sterility cannot be ensured without direct observation. An unguarded sterile field should be considered contaminated. 10. Sterile persons keep well within sterile area. A. Sterile persons pass each other back to back or front to front. B. Sterile person faces a sterile area to pass it. C. Sterile persons stay within the sterile field. They do not walk around or go outside the room. D. Movement is kept to a minimum to avoid contamination of sterile items or persons. 11. Unsterile persons avoid sterile areas. A. Unsterile persons maintain a distance of at least 1 foot from the sterile field. B. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it. C. Unsterile persons never walk between two sterile fields. D. Circulator restricts to a minimum all activity near the sterile field. 12. Destruction of integrity of microbial barriers results in contamination. A. Strike through is the soaking through of barrier from sterile to non-sterile or vice versa. B. Sterility is event related.

13. Microorganisms must be kept to irreducible minimum. A. Perfect asepsis is an idea. All microorganisms cannot be eliminated. Skin cannot be sterilized. Air is contaminated by droplets.

UNIVERSAL PRECAUTIONS SUMMARYAlthough the risk of contracting HIV in the healthcare setting is extremely low, there are other bloods borne pathogens which pose a much more significant risk. Precautions should be followed to reduce the risk of exposure to blood borne pathogens. Each healthcare worker should assess their possible risks and take precautions to reduce these risks. Universal Precautions are designed to protect healthcare workers from occupational exposure and should be followed when potential for exposure might occur. Universal blood and/or body fluid precautions should be consistently used for ALL patients. Fundamental to the concept of Universal Precautions is treating all blood and/or body fluids as if they were infected with blood borne pathogens and taking appropriate protective measures, including the following: o Gloves should be worn for touching blood and/or body fluids, mucous membranes, non-intact skin, or items/surfaces soiled with blood and/or body fluids. Gloves should be changed after contact with each patient and hands washed after glove removal. Though gloves reduce the incidence of contamination, they cannot prevent penetrating injuries from needles and other sharp instruments.

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Gowns or aprons should be worn during procedures that are likely to generate splashes of blood and/or body fluids onto clothing or exposed skin.

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Masks and protective eyewear should be worn during procedures that are likely to generate droplets of blood and/or body fluids into the mucous membranes of the mouth, nose, or eyes.

o Needles and sharps should be placed directly into a puncture-resistant leak proof container which should be as close as possible to the point of use. Needles should not be recapped, bent, broken, or manipulated by hand.

o Hands and skin surfaces should be washed after contact with blood and/or body fluids, after removing gloves, and between patient contacts.

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Gloves should be worn to cleanup blood spills. Blood spills should be wiped up the disinfectant should have a one minute contact time and the area rinsed with tap water. If glass is involved, wear double gloves or heavy gloves. Pick up the glass with broom and dust pan, tongs, or a mechanical device.

o Healthcare workers with exudative lesions or weeping dermatitis should not perform direct patient care until the condition resolves.

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Disposable resuscitation devices should be used in an emergency.

PRECAUTIONS FOR THE SURGICALTEAMSafety in the operating room, both for patients and staff, requires careful planning, use of appropriate personal protective equipment (PPE) and demands daily attention and maintenance by the surgical team members and support staff. While traditionally the focus of attention in the OR has been almost totally directed to protecting the patient, the emergence of the HIV/AIDS crisis, increasing HCV rates and resurgence of tuberculosis necessitate that equal attention be given to protecting health workers and professional staff The following section contains safety checklists for the surgical team that have been adapted from an operating room safety manual by Davis (2001). They are intended to serve as general guides to improving safety in the operating room. In addition, they serve as reminders and as means of raising awareness of risk.

GENERAL SAFETY CHECKLIST (FOR SURGICAL TEAM)Absolute prerequisites y Use Standard Precautions with all patients. Personal protective equipment appropriate choices y Use adequate eye and face protection. y Wear fluid-resistant or fluid-impervious gowns, as appropriate to expected exposure risk (if available). y Choose gloves appropriately (use double gloving,). y Wear appropriate footwear (shoes not open toed or flip flops). Personal protective equipment appropriate use y Remove gloves carefully to avoid blood splatter. y Wash hands with soap and clean water or use antiseptic hand scrub after removing gloves. y Remove eye protection last. y Remove contaminated personal protective equipment (PPE) before leaving the room. y Carefully remove and discard mask following every procedure. Safety techniques y Wear examination gloves when handling surgical specimens. y Wear eye protection if container is opened or splashing is anticipated. y Apply dressings and handle drains or packs wearing clean new examination gloves. y Avoid touching any surface with contaminated gloves. Safety strategies y Have extra PPE readily available should replacements be needed. y Position sharps disposal containers at point of use. y Have a plan for sharps management. y Make sure all team members know the plan. y Modify the plan as needed. y Focus attention on sharps in use; be aware and alert. y Alert other OR team members to possible hazards. y Discourage unauthorized entry into the room. y Keep extraneous conversation to a minimum. Personal preparation y Prepare your body and mind to function effectively and efficiently. y Get enough sleep before surgery. If you are working a long shift on obstetrics or trauma service, nap if and when you can. y Avoid caffeine, which increases hand tremor. y Avoid alcohol or other substances that impair perception, judgment or reflexes. y Promote general good health. Exercise regularly and have an annual physical.

SAFE ASSISTING AND OPERATING CHECKLISTy y y y Use forceps to put scalpel blade on handle. Avoid handling suture needles manually. Never hold a scalpel, loaded needle holder, or any other sharp in the same hand simultaneously with another instrument. Scalpels, loaded needle holders, and other sharps should be held in the hand only during cutting, suturing, or for other specific tasks. At all other times, sharps should be placed off the operative field. Properly employ a Safe Zone for the safe passing of sharps. Use verbal warnings to announce transfer of sharps. Before tying, either remove the needle from the suture and park the needle safely, or protect the needle point with the needle holder. Avoid finger contact with tissue being sutured or cut. Use retractors rather than manual retracting whenever possible. Avoid reflex sponging of tissue, which may not be anticipated by the surgeon, when a sharp is in use. Keep eyes on all sharps in use until they are returned to the Safe Zone. Pass long laparoscopic instruments, such as needle tip cautery and sharp-pointed scissors, handle first and tip down. When doing repeat injections with hypodermic needle and syringe, stick needle in rolled, sterile towel when not in use. Remove scalpel blade using forceps; place in sharps container.

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OPERATING ROOM SAFETY CHECKLISTPERSONAL PROTECTIVE EQUIPMENT y Head wear that covers scalp hair y Eye and face protection in place y Appropriate gown y Double gloves or glove liners as indicated y Waterproof drapes (if available) WORK PRACTICE CONTROLS y Appropriate suture needle selection (blunt if applicable) y Appropriate retractor selection (blunt if applicable) y Disposable scalpels (if available) SHARPS MANAGEMENT y Sharps disposal container

DELIVERY ROOM SAFETY CHECKLISTPERSONAL PROTECTIVE EQUIPMENT y Head wear that covers scalp hair y Eye and face protection in place y Appropriate gown y Double gloves, extended cuff gloves (gauntlet) or glove liners as indicated y Waterproof drapes (if available) WORK PRACTICE CONTROLS y y Appropriate suture needle selection (blunt if applicable for episiotomy) Appropriate retractor selection (blunt if applicable for cesarean section)

SHARPS MANAGEMENT y Sharps disposal container

MINIMALLY INVASIVE SURGERY SAFETY CHECKLISTy y y Pass trocars, needles, and other short-length sharps through a Safe Zone. Pass long laparoscopic instruments that dont fit in the Safe Zone, such as needle-tip cautery and sharp-pointed scissors, handle first and tip down. Place long-pointed cautery needles, hollow-bore needles or other long sharps into sleeve ports, on request only, using two hands preferably one persons hands and then angle the handle toward the surgeons waiting hand. Blunt-tipped suture needles may be used effectively during laparoscopic hysterectomy and are considered a safer option for patient and surgeon. Aspirate all gas, fluid, and blood from the abdomen prior to closing.

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SAFE SHARPS DISPOSAL CHECKLISTy y y y y y y y Choose containers with built-in safety features, such as see-through (translucent) boxes with a readily apparent three fourths and full level lines. Lids should allow the sharp to enter the container by gravity alone, without the need for Install containers close to the point of use ideally within arms reach. Mount containers at a convenient height for use and service, in plain sight and free from Obstructions. Do not leave containers freestanding on the floor on their side. Do not shake containers to avoid spillage or sharps sticking out. Schedule staff training and education for proper use of sharps containers. Assign responsibility for maintenance and service of sharps containers.

DUTIES AND RESPONSIBILITIES TO ENSURE SAFETY IN THE OPERATING ROOMScrub Nurse/TechnicianA. Preoperative 1. Checks the card file for surgeon's special needs/requests. 2. Opens sterile supplies. 3. Scrubs, gowns, and gloves and sets up sterile field. Obtains instruments from flash autoclave if necessary. Checks for proper functioning of instruments/equipment. 4. Performs counts with circulator. B. Preincisional 1. Completes the final preparation of sterile field. 2. Assists surgeon with gowning/gloving. 3. Assists surgeon with draping and passes off suction/cautery lines.

C. During the Procedure 1. 2. 3. 4. Maintains orderly sterile field. Anticipates the surgeon's needs (supplies/ equipment). Maintains internal count of sponges, needles and instruments. Verifies tissue specimen with surgeon, and passes off to circulator.

D. Closing Phase 1. 2. 3. 4. 5. 6. Counts with circulator at proper intervals. Organizes closing suture and dressings. Begins clean-up of used instruments. Applies sterile dressings. Prepares for terminal cleaning of instruments and nondisposable supplies. Reports to charge nurse for next assignment.

Circulating NurseA. Preoperative 1. 2. 3. 4. 5. Assists in assembling needed supplies. Opens sterile supplies. Assists scrub in gowning. Performs and records counts. Admits patient to surgical suite.

B. Preincisional 1. 2. 3. 4. 5. Transports patient to procedure room. Assists with the positioning of the patient. Assists anesthesia during induction. Performs skin prep. Assists with drapes; connects suction and cautery.

C. During the Procedure 1. 2. 3. 4. 5. 6. Maintains orderly procedure room. Anticipates needs of surgical team. Maintains record of supplies added. Receives specimen and labels it correctly. Maintains charges and O.R. records. Continually monitors aseptic technique and patients needs.

D. Closing Phase Counts with scrub at proper intervals. Finalizes records and charges. Begins clean-up of procedure room. Applies tape. Assists anesthesia in preparing patient for transfer to PACU. Takes patient to PACU with anesthesia and reports significant information to PACU nurse. 7. Disposes of specimen and records. 8. Reports to charge nurse for next assignment. 1. 2. 3. 4. 5. 6.

SURGICAL AND INVASIVE PROCEDURE PROTOCOL A. SCHEDULINGScheduling must include: 1. Entire procedure, exact site, level, digit, and side/laterality (including spelling out Left, Right and Bilateral no abbreviations other than C-Cervical, T-Thoracic, L-Lumbar, S-Sacral when identifying spinal levels e.g. L4-5). 2. Specific information on implant/implant system and/or equipment. 3. Specific information on removal of device. 4. Information on harvest and donor sites. 5. The Operating Room (OR), or the person responsible for accepting requests to schedule procedures, must verify the information provided by the surgeon/physician. The information should be verified in a manner agreed to by both the institution and physicians

B. CONSENT DOCUMENT Consent documentation must include: 1. First and last name, date of birth of patient and medical record number of the patient. 2. Name and description of surgery or procedure in terms that are understandable to the patient (correct site/side, level and digit with the side spelled out as Left, Right or Bilateral). 3. No acronyms or abbreviations (except spinal levels noted). 4. Specific implant/implant system to be placed or device to be removed. 5. Patient/family/guardian/health care agent signature and date. 6. Witness signature and date. 7. Physician signature and date. 8. If the consent is altered or illegible it must be re-done and re-signed by all parties.

C. PRE-OPERATIVE/PRE-PROCEDURAL VERIFICATION PROCESS Verification of the correct person, procedure site and side must occur (as applicable): 1. At the time the surgery or invasive procedure is scheduled. 2. at the time of admission or entry into the facility. 3. with the patient involved, awake and aware, if possible. 4. Anytime the responsibility for care of the patient is transferred to another caregiver or location in the pre-operative or pre-procedural process. 5. before the patient leaves the pre-operative area or enters the procedure/surgical room.

A pre-operative or pre-procedural verification checklist must be utilized to ensure availability and actual review of the following, prior to the start of the procedure: 1. Relevant documentation: History & Physical, signed consent and any other documents required by the organization as part of the pre-operative evaluation process. The consent must be signed by the patient/legal representative, and surgeon. 2. Relevant images properly labeled and displayed including photographs. In High Risk procedures (as determined by the surgeon), the images should be reviewed by the surgeon and radiologist together pre-operatively. Someone other than the primary surgeon confirms the name, date of the study and Left-Right orientation. The surgeon is responsible for assessing what films/images is appropriate for viewing before and during the surgery. When intra-operative imaging studies are performed, appropriate consultation should be available for interpretation of intra-operative studies. 3. Relevant diagnostic reports or studies (ultrasound, endoscopy, etc.). 4. Relevant pathology reports. 5. Necessary patient-specific implants and special equipment. 6. Confirm identity using two (2) identifiers; confirm procedure and site marking if appropriate.

D. MARKING THE OPERATIVE/PROCEDURAL SITE 1. The physician doing the procedure must do the site marking using his/her own initials. Site marking must be legible and unambiguous (see exceptions). 2. All sites involving laterality (e.g. brain) and/or paired organs, multiple structures (fingers, toes, hernias, lesions) or multiple levels (spine). Make the mark at or near the incision site(s) so that it/they will be visible when the patient is draped 3. For hand and foot surgery, the surgeon must mark the surface(s) of the digit to be operated on, anterior, posterior or both. 4. The appropriate site must be verified before any cast is split. For relevant orthopedic cases, the skin/site should be marked immediately after cast/splint is removed. 5. For surgery of the spine, pre-operative skin marking is required to indicate laterality, when appropriate. A second time out must be performed when the intra-operative imaging is done to confirm the level. 6. When the site or level is not visually identifiable, the surgeon must obtain an intraoperative image, using markers that will not move, to confirm the exact level/site. 7. Do NOT mark any non-operative site(s). 8. The mark must be visible in the operative field after the patient is prepped and draped. 9. Adhesive site markers should not be used as the sole means of marking the site.

10. In the event of multiple surgical procedures by different surgeons, all relevant surgical sites must be marked prior to the first surgery. The surgeon marking the site(s) must be present for and participate in the time out performed for each procedure he/she marks. 11. Marking must take place with the patient/family involved, awake and aware, if possible. 12. If a smaller mark is necessary, such as near the eye cases, a dot near the eye constitutes the site marking. A special purpose wristband is also an option. 14. Final verification of the site mark must take place during the "time out".

PATIENTS SAFETY : THE SURGICAL CHECKLISTA detailed account of the duties and responsibilities required by each person at each stage of the checklist. Having a working knowledge of this document will ensure that the briefings and checklists are conducted correctly, and will avoid delays in the operating room. It can also be used a learning tool and reference guide to ensure sustained proficiency.

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Before Induction

Just prior to induction after all tasks have been completed, the Anesthesiologist will call for the Before Induction Checklist. The Circulating nurse will read the checklist and the Anesthesiologist will ensure the task has been completed and respond with the appropriate answer The Anesthesiologist will then continue with induction. y Anesthesia Safety Check complete .. YES The anesthesiologist confirms his or her agreement by stating yes. y Patient consent obtained .. YES (sn)

The scrub nurse confirms his or her agreement by stating yes. The circulating and scrub nurse have checked the patient consent form. If there are any consent concerns they must be reconciled before continuing with the checklist. Refer to Surgical Consent policy and procedure for further information. y Patient Identification confirmed ... YES (all) The anesthesiologist, Scrub and Circulating Nurses confirm that they have previously checked the patients name by stating yes. Prior to entering the operating room the anesthesiologist interviews the patient and confirms identification. Nurses check the patients chart and identify the patient before surgery, often in a pre-operative holding or admitting area.

y Site and procedure confirmed ..... YES The anesthesiologist confirms his or her agreement by stating yes. The anesthesiologist and nurses have verbally confirms with the patient the surgical site and procedure. Refer to Fraser Health Correct Site for Surgical Procedure, y Site marked YES / NOT REQUIRED The anesthesiologist confirms his or her agreement by stating yes. or not required If site marking is required the surgeon marks the surgical site prior to the patient entering the room. The anesthesiologist visually confirms the site is marked prior to induction. Refer to Fraser Health Correct Site for Surgical Procedure. y Pulse Oximeter on and functioning .. YES The anesthesiologist confirms his or her agreement by stating yes. Ideally, the pulse oximetry should be visible to the operating team. An audible system should be used when possible to alert the team to the patients pulse rate and oxygen saturation. y Known allergy . NO / YES, Specify The anesthesiologist answers the question No or Yes. If yes the type and severity of allergy is stated. If the circulating nurse knows of an allergy that the anesthesiologist is not aware of, this information should be communicated at this time. y Difficult airway NO / YES assistance available The anesthesiologist answers the question No or Yes. If yes the anesthesiologist confirms adequate equipment and assistance present. y Risk of >500ml blood loss NO / YES adequate IV access The anesthesiologist answers the question No or Yes. If yes, adequate IV access, adequate blood and fluids, and adequate available equipment must be available. Guidelines for blood loss are as follows; Adults > 500ml and children 7ml/kg. If there is a significant risk of blood loss the World Health Organization highly recommends that at least two large bore intravenous lines or a central venous line. At the end of the before induction checklist the Circulating Nurse will say; Before Induction Checklist Complete

Before Skin IncisionJust prior to skin incision or other interventions and after all tasks have been completed, the Surgeon will call for the Before Skin Incision checklist. The Circulating nurse will read the checklist and the appropriate team member will ensure the task has been completed and respond with the appropriate answer. At the end of the checklist the Circulating Nurse will say; Before skin incision checklist complete. The Surgeon will advise the team that the surgery will begin. The Before Skin Incision checklist requires less than thirty seconds to complete, and replaces the surgical pause.

y Before Skin Incision Checklist Prior to start of procedure or skin incision (initiated by Surgeon) The circulating nurse will read the checklist. y Patients name confirmed YES (all) The surgical team members will confirm their agreement by stating Yes. The Anesthesiologist and Nurses confirmed the patients name prior to induction. The Surgeon stated the patients name aloud during the briefing. Stating yes confirms that all are in agreement to the patients identification. If the name was not stated aloud by the Surgeon during the briefing or if a briefing was not conducted the name must be stated aloud at this time. The circulating nurse will ask the surgeon to state the patients name. y Procedure and Site confirmed YES (all) The surgical team members will confirm their agreement by stating Yes. If there is any doubt, consensus must be reach prior to continuing the checklist y Antibiotic Prophylaxis within 60 minutes ... YES / NOT REQUIRED The surgeon will answer the question Yes or Not Required The Surgeon will confirm that antibiotic prophylaxis has been given within the last 60 minutes. If re- dosing is required during the case and was not discussed during the briefing it should be discussed prior to continuing with the checklist. If prophylactic antibiotics have not been administered, they should be administered now, prior to incision. If prophylactic antibiotics have been administered longer than 60 minutes before, the team should consider re-dosing the patient before the skin incision. y Essential Imaging displayed .......... YES / NOT REQUIRED The Surgeon will answer the question Yes or Not Required. Imaging is critical to ensure proper planning and conduct of many operations, including orthopedic, spinal and thoracic procedures and many tumor resections. Essential imaging includes x-rays, angiograms, CT scans, and MRI scans that display the operative site. Essential imaging may also display areas of the body that add risk to the operative procedure, for example the neck in patients with rheumatoid arthritis, and the chest in patients with lung disease. If imaging is needed but not available, it should be obtained. The surgeon will decide whether to proceed without the imaging if it is necessary but unavailable. . Does anyone have questions or concerns before we begin? This final question will be asked by the Circulating Nurse. This is an important time to discuss issues or concerns that may affect patient or clinician safety that have not been addressed previously. The Circulating Nurse will state Before Skin Incision Checklist Complete At this point the team may proceed with the case.

Surgeons Team Briefing (before surgery)Patients name The Surgeon will state the patients name aloud. The name must coincide with the name previously confirmed by Anesthetists the Nurses prior to induction. Procedure, site and site marked The Surgeon will state aloud the procedure to be performed, identify the site and state that the site is marked or that site marking is not required. If site marking is required and has not been marked, it will be marked prior to continuing with the briefing. General overview of the procedure and duration The Surgeon will give a general overview of the procedure to be completed and state the anticipated duration. Required Equipment, Instruments, imaging, implants The Surgeon will discuss with the team all necessary requirements with regards to equipment, Instruments, imaging, implants etc.

Patient positioning, warming, DVT and antibiotics (re-dose) The Surgeon will discuss the requirements with regards to Patient positioning, warming devices, and antibiotic prophylaxis including possible re-dose of drugs. Anticipated Critical Events: Surgeon Review: The Surgeon will discuss with the team all specific patient concerns, blood loss, critical steps, staffing, special equipment and any other issues affecting patient safety. Anesthesia Review: The Anesthetist will discuss with the team any specific patient concerns, resuscitation plan, medications, and any other issues affecting patient safety Nursing Review: The Nurses will discuss with the team all specific patient concerns, equipment, implants, supplies, staffing, and any other issues affecting patient safety

Introduction and role of all team membersThe Surgeon may introduce all team members or may choose to have team members introduce themselves. The role of each team members should also be discussed. Note: If the team is together for several cases during the day, introductions are only required for the first case of the day, or when new clinicians join the team and change in roles.

Surgeons Team DebriefingTo be completed by the Surgeon prior to the patient leaving the room The Surgeon will verbally confirm the following with the team Instrument, sponge and needle count The Surgeon shall confirm with the nursing team that the count is complete and accurate. The circulating and scrub nurses should verbally confirm the completeness of final sponge and needle counts. In cases with an open cavity, instrument counts should also be confirmed as complete Specimen labeling The Surgeon shall confirm with the nursing team that all labeling is complete and accurate. The circulating nurse confirms the correct labeling of any specimens obtained during the procedure by reading out loud the patients name, the specimen description, and any orienting marks or sutures. The management/handling and labeling of all specimens must be completed before the surgical procedure setup is dismantled. Incorrect labeling of specimens is potentially disastrous for a patient and has been shown to be a frequent source of laboratory error. Refer to policies and procedures for handling of specimens. Procedure performed and unplanned events The Surgeon shall state the procedure performed and discuss any unplanned events. The circulating nurse will document the procedure(s) on the operative record. The purpose of this step is to have complete and accurate documentation and transfer of critical information to the recovery room team.

Patient recovery concerns and management plan / destination The surgeon, anesthesiologist and nurse should review the post-operative recovery and management plan, focusing in particular on intra operative or anesthetic issues that might affect the patient. Events that present a specific risk to the patient during recovery and that may not be evident to all involved are especially pertinent.

Equipment shortages / malfunctions reviewed The team will discuss equipment shortages or malfunctions and document if necessary Equipment problems are universal in operating rooms. Accurately identifying the sources of failure and instruments or equipment that have malfunctioned is important in preventing devices from being recycled back into the room. The circulating nurse should ensure that equipment problems arising during a case are identified by the team. The teams concerns will be communicated to the applicable departments involved in resolving problems identified Surgical wound classification The surgical wound classification will be determined and documented The surgeon and the circulating nurse will review the classification of the surgical wound. If the wound classification was downgraded during the procedure due to contamination, the circulating nurse will change the classification and document on the nurses notes why this was done. The circulating nurse will also document any reprocessing (flashing) of instruments and the reason why this was done Could anything have been done to make this case safer or more efficient? The Surgeon will ask the team if anything could have been done differently or if anyone has suggestions or concerns.