Appendix E. Endoscopy Checklist Template - Implementation Guide
Endoscopy Safety Checklist - Preprocedure Area/Procedure Room
| Before Patient Enters Room |
| Nurse, Anesthesia Professional, and Patient Review: |___| Patient identification (name and date of birth) |___| Procedure to be performed matches the consent |___| Known allergies |___| Patient height, weight, body mass index |___| History and physical |
| Anesthesia Professional and Nurse Discuss: |___| Anesthesia safety check is completed |___| Type of anesthesia |___| Anticipated airway and aspiration risk |___| Patient-specific concerns |
| Before Procedure Begins |
| Team Introductions |___| Please state your name and role |
| Proceduralist Shares: |___| Any changes to the plan and possible difficulties |___| Necessary equipment/devices are available Anesthesia Professional Shares: |___| Anesthetic plan |___| Airway and other concerns Nursing Team Shares: |___| Any equipment issues |___| Other concerns Nursing Team Confirms: - All medications correct and labeled |
| |___| Is everyone ready to perform the timeout? |
| The Team Performs The Timeout |___| Patient's name |___| Procedure to be performed matches the consent form |___| Procedure site |
| Proceduralist States: - "Does anybody have any concerns? If you see something that concerns you during this case, please speak up." |
| Before Patient Leaves Room Debriefing |
| Nurse Reviews With Team: |___| Name of the procedure performed |___| Identify/confirm patient restriction for diet or activity in recovery interval |___| Specimen labeling - Read back specimen labeling including patient's name |
| Team Discusses: |___| Equipment problems that need to be addressed |___| Key concerns for patient recovery and management |___| Whether anything can be done to make the next case safer or more efficient |
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
Based on the WHO Surgical Safety Checklist, www.who.int/patientsafety/safesurgery/checklist/en/index.html,
© World Health Organization 2009. All rights reserved.
