1. Questionnaire Ensuring Correct Surgery and Invasive Procedures
Pre-Training Questionnaire
Rank your confidence level regarding each of the following statements using scale below:
Not confident at all < > Completely confident
I am confident in my understanding of . . .
the definition of a surgical or non-surgical invasive procedure
the use of a checklist prior to the start of an invasive procedure
the system factors that contribute to incorrect procedures
“speaking up” when something does not seem quite right
the actions to be taken when a team member is not able or refuses to
follow the steps to ensure correct site surgery and invasive procedures
6. the Ensuring Correct Surgery and Invasive Procedure Directive as
applied in special circumstances (e.g. endoscopy)
7. when the time-out process occurs and who must participate
8. the key components of marking the procedure site
9. the important elements of proper patient identification
10. the correct method for reviewing imaging studies prior to commencing
an operation or invasive procedure
Questionnaire

2. Ensuring Correct Surgery and Invasive Procedures
Observational Checklist
Facility _________ Date________ Time Block_______ Team_______ Rater _______
Yes No
N/A
Consent
The consent form was reviewed for correct:
Patient name
Procedure site including laterality (if applicable)
Name and description of procedure
Reason (condition or diagnosis) for performing procedure
Patient and Procedure Site Identification
Patient was asked to verbally state their name and a facility-approved unique identifier
Patient was asked to state location of procedure on their body
Site Marking
The site was marked to clearly indicate the procedure site
The patient was involved in site marking
Operative site was marked prior to administration of anesthesia
Mark was visible when the patient was positioned and draped
For spine surgery: intra-operative radiographic confirmation of vertebral level (with makers that do not move) performed to confirm the site
Review of Medical Images
Pertinent medical images were reviewed by two members of the procedure team prior to commencing the procedure
Time-out
A time-out facilitated by a checklist was performed immediately before the start of the procedure
All staff involved in the procedure were present in the room for time- out
All staff actively participated in the time-out (ie. all other work stopped, staff responded verbally)
All checklist items were addressed
Staff members spoke up when they noticed something that could lead to patient harm
Correct implant was confirmed, including a “read-back” of relevant information (ie. implant name, size)
ECS Observation Checklist Tool