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 < 1-------------2--------------3--------------4-------------5 > Completely confident

I am confident in my understanding of . . .

•the definition of a surgical or non-surgical invasive procedure . . . . . . . . . 1 2 3 4 5

•the use of a checklist prior to the start of an invasive procedure . . . . . . . .1 2 3 4 5

•the system factors that contribute to incorrect procedures . . . . . . . . . . . 1 2 3 4 5

•“speaking up” when something does not seem quite right . . . . . . . . . . . . 1 2 3 4 5

•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 . 1 2 3 4 5

6. the Ensuring Correct Surgery and Invasive Procedure Directive as applied in special circumstances (e.g. endoscopy) . . . . . . . . . . . . . . . . . 1 2 3 4 5

7. when the time-out process occurs and who must participate . . . . . . . . . 1 2 3 4 5

8. the key components of marking the procedure site . . . . . . . . . . . . . . . . . .. 1 2 3 4 5

9. the important elements of proper patient identification . . . . . . . . . . . . . 1 2 3 4 5

10. the correct method for reviewing imaging studies prior to commencing an operation or invasive procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5

Ensuring Correct Surgery and Invasive ProceduresObservational Checklist

Facility _________ Date________ Time Block_______ Team_______ Rater _______