Which department are you completing this survey for?

Name of the employee observed:

select

Patient MRN?

Select Audit

Patient verified using two patient identifiers?

Time out completed after induction and before prep and drape?

All members of the team are present and engaged (if 1 prep/drape)

If no, please select all team members that were not present and engaged

All team members present and engaged

No, Surgeon/Proceduralist [Non-Compliant Answer]

No, Anesthesiologist [Non-Compliant Answer]

No, OR RN [Non-Compliant Answer]

No, Surgical Tech [Non-Compliant Answer]

The procedure and site marking (if applicable) is read from the consent form?

Site marking verified

Anesthesia Time Out Performed

Block site verified with Surgical & Anesthesia Consents?

Anesthesia Consent contains type of block and site?