INVASIVE PROCEDURE SAFETY CHECKLIST: Tracheostomy TIME OUT BEFORE THE PROCEDURE Verbal confirmation between team members before start of Have all members of the team procedure Yes No introduced themselves? Is patient on adequate ventilator Yes No Patient identity checked as correct? Yes No settings and 100% FiO2? SIGN OUT Is patient adequately sedated and Yes No Appropriate consent completed? Yes No paralysed? Tracheostomy position confirmed Is suitable tracheostomy and equipment Yes No Yes No Is position optimal? with Bronchoscope? available? (difficult airway Yes No trolley/bronchoscope) Cuff tested as intact? Capnography in situ? Yes No Is appropriate monitoring available? All team members identified and roles Yes No Ventilator settings reviewed post Yes No Yes No (including EtCO2) assigned? procedure? Are there any Contraindications to Yes No Any concerns procedure? Sedation reviewed? Yes No performing the procedure? (High FiO2, Yes No Post procedure hand over given to If you had any concerns about the procedure, how were PEEP, anatomical, vascular, Yes No nursing staff? these mitigated? coagulopathy) Medicines and coagulation checked? Yes No Any Known drug allergies? Yes No Signature of Is feed stopped and NG aspirated? Yes No responsible clinician completing the form Are spinal precautions required? Yes No Are there any concerns about this Yes No procedure for the patient? Level of difficulty anticipated prior to the start of the procedure None Possibly Difficulty anticipated difficult anticipated Procedure date: Names and registering body numbers of clinicians Time: responsible for the procedure Operator: 1. Observer: 2. Assistant: Level of supervision: SpR Consultant 3. Equipment & trolley prepared:
INVASIVE PROCEDURE SAFETY CHECKLIST: Tracheostomy BEFORE THE PROCEDURE Have all members of the team introduced themselves? Yes No Patient identity checked as correct? Yes No Appropriate consent completed? Yes No Is suitable tracheostomy and 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 Level of difficulty anticipated prior to the start of the procedure None anticipated Possibly difficult Difficulty anticipated 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 Cuff tested as intact? All team members identified and roles assigned? Yes No Any concerns 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 Tracheostomy position confirmed with Bronchoscope? Yes No Capnography in situ? Yes No Ventilator settings reviewed post procedure? 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_-_tracheostomy_word_version.docx