INVASIVE PROCEDURE SAFETY CHECKLIST: NG Tube Insertion TIME OUT BEFORE THE PROCEDURE Verbal confirmation between team members before start of Patient identity checked as correct? Yes No procedure Base of # ruled out if Appropriate consent completed? Yes No Yes No NEX measurement ( applicable? SIGN OUT Yes No cms) Is position optimal? Yes No Any equipment issues? Yes No Are there any All team members identified Is a chest X-ray required? Yes No contraindications to and Yes No Is aspirate below pH 5.5? Yes No performing the procedure? roles assigned? Yes No Post procedure hand over given to Yes No (Coagulopathy/base of skull#/ Any concerns about procedure? Yes No nursing staff? previous sphenoidal surgery) If you had any concerns the procedure, how were these mitigated? Are there any concerns about this Yes No Signature of procedure for the patient? responsible clinician and registering body numbers of clinicians responsible completing the form for the procedure 1. 2. 3. Procedure date: Time: Operator: Observer: Assistant: Level of supervision: SpR Consultant Equipment & trolley prepared:
INVASIVE PROCEDURE SAFETY CHECKLIST: NG Tube Insertion BEFORE THE PROCEDURE Patient identity checked as correct? Yes No Appropriate consent completed? Yes No NEX measurement ( cms) Yes No Are there any contraindications to performing the procedure? (Coagulopathy/base of skull#/ previous sphenoidal surgery) Yes No Are there any concerns about this procedure for the patient? Yes No and registering body numbers of clinicians responsible for the procedure 1. 2. 3. TIME OUT Verbal confirmation between team members before start of procedure Base of # ruled out if applicable? 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 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 Is a chest X-ray required? Yes No Is aspirate below pH 5.5? Yes No Post procedure hand over given to nursing staff? Yes No Signature of responsible clinician completing the form
invasive_procedure_safety_checklist_-_ng_tube_insertion_word_version.docx