INVASIVE PROCEDURE SAFETY CHECKLIST: Bronchoscopy TIME OUT BEFORE THE PROCEDURE Verbal confirmation between team members before start of Patient identity checked as correct? Yes No procedure SIGN OUT Is patient on adequate ventilator Yes No Appropriate consent completed? Yes No settings and 100% FiO2? Any equipment issues? Yes No Is suitable equipment available? Yes No Is patient adequately sedated and Yes No (Difficult airway trolley/bronchoscope) Capnography in situ? Yes No paralysed? Is appropriate monitoring available? Ventilator settings reviewed post Yes No Yes No Is position optimal? Yes No (including EtCO2) procedure? All team members identified and roles Yes No Are there any contraindications to Is a chest X-ray required? Yes No assigned? performing the procedure? (High FiO2, Yes No Sedation reviewed? Yes No Yes No PEEP, anatomical, vascular, Any concerns about procedure? coagulopathy) Post procedure hand over given to Yes No If you had any concerns about the procedure, how were nursing staff? Medicines and coagulation checked? Yes No these mitigated? Any known drug allergies? Yes No Is feed stopped and NG aspirated? Yes No Signature of Are spinal precautions required? Yes No responsible clinician Are there any concerns about this completing the form Yes No procedure for the patient? Names and registering body numbers of clinicians responsible for the procedure 1. 2. Procedure date: 3. Time: Operator: Observer: Assistant: Level of supervision: SpR Consultant Equipment & trolley prepared:
INVASIVE PROCEDURE SAFETY CHECKLIST: Bronchoscopy BEFORE THE PROCEDURE Patient identity checked as correct? Yes No Appropriate consent completed? Yes No Is suitable equipment available? (Difficult airway trolley/bronchoscope) Yes No Is appropriate monitoring available? (including EtCO2) Yes No Are there any contraindications to performing the procedure? (High FiO2, PEEP, anatomical, vascular, coagulopathy) Yes No Medicines and coagulation checked? Yes No Any known drug allergies? Yes No Is feed stopped and NG aspirated? Yes No Are spinal precautions required? Yes No Are there any concerns about this procedure for the patient? Yes No Names and registering body numbers of clinicians responsible for the procedure 1. 2. 3. TIME OUT Verbal confirmation between team members before start of procedure Is patient on adequate ventilator settings and 100% FiO2? Yes No Is patient adequately sedated and paralysed? Yes No Is position optimal? Yes No All team members identified and roles assigned? Yes No Any concerns about procedure? Yes No If you had any concerns about the procedure, how were these mitigated? Procedure date: Time: Operator: Observer: Assistant: Level of supervision: SpR Consultant Equipment & trolley prepared: SIGN OUT Any equipment issues? Yes No Capnography in situ? Yes No Ventilator settings reviewed post procedure? Yes No Is a chest X-ray required? Yes No Sedation reviewed? Yes No Post procedure hand over given to nursing staff? Yes No Signature of responsible clinician completing the form
invasive_procedure_safety_checklist_-_bronchoscopy_word_version.docx