Anesthesia Block Time-out

Name of the employee observed:

Patient MRN?

Department Name
Was a timeout completed?
Patient identified using two patient identifiers?
Surgical Consent checked?
Surgical site checked?
SIDE of block identified? (if applicable)
Anesthesiology Consent checked?
Block type stated?
Time-out completed after positioning of block?
Allergies verified?
Medication and dose stated?
Anticoagulation verified?
Skin prep restriction verified?