Perioperative Patient Record – Preoperative Checklist
Poor communication is the single most frequent cause of adverse events across all facets of healthcare
resulting in problems that range from delays in treatment to medication errors and / or wrong site surgery.
Patient safety is of particular significance during surgical interventions as patients are especially
vulnerable during this time
1-4
.
Transitions in care in the perioperative environment are numerous and should be considered high-risk
endeavours. Historically, the goal of preoperative assessment has been to determine patient factors that
significantly increase the risk of perioperative complications
5
. In recent years, many hospitals have
started using comprehensive checklist procedures which have demonstrated improvements in teamwork
and patient safety in the perioperative environment
6,7
.
The Preoperative Checklist context document was developed by the Statewide Preoperative Checklist
Review Working Group to support Queensland Health clinicians in the preparation of patients for surgery.
CONSIDERATIONS
The Perioperative Patient Record has three components consisting of the Preoperative Checklist, Surgical
Safety Checklist
8
and pages (2 and 3) on which variances, alerts and additional information is recorded.
The Preoperative Checklist is completed by clinicians working within their scope of clinical practice and
is designed to aid patient preparation prior to their transfer to theatre and support effective clinical
handover when there is a transfer of professional responsibility and accountability.
The Preoperative Checklist provides for three checks to be completed. A minimum of two checks are to
be undertaken. The need for a third check is dependent on the workflow of individual health service
facilities. As an example:
Check 1 completed by clinicians in the ward/admission area
Check 2 completed by clinicians admitting patients into the perioperative department
Check 3 completed by operating theatre clinicians prior to the patient entering the operating theatre.
As check 3 is optional, please following local workplace / workflow requirements.
The context document has been developed as an educational tool. It provides clinicians with relevant
information and instructions on how to complete the checklist. A ‘lift out’ quick reference guide is also
provided (Refer to Appendix 1).
Check 1
Whilst engaging with the patient, clinicians are required to read each question carefully and tick the
applicable check box relating to each question within the checklist.
Individual check boxes may include the prompt ‘(document as variance)’. Additional information pertaining
to variances is documented in the relevant sections on pages 2 and 3 of the checklist. If there is insufficient
space available in individual sections to record all relevant variances, utilise the ‘Additional variances’
section provided.
Check 2 and Check 3
Checks 2 and 3 involve reviewing the information collected during Check 1, ensuring it is fully completed
and accurate. When reviewing each answer, a tick should be placed in the ‘Confirmed’ column to indicate
the information noted in Check 1 has been reviewed and confirmed as correct.
Statewide Anaesthesia and Perioperative Care Clinical Network
CONTEXT DOCUMENT
2
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
In addition, when reviewing each answer, a tick must be placed in the ‘Variance’ column for each item
where a variance has been identified and documented.
At the end of Checks 2 and 3, every item will have a tick in the ‘Confirmed’ column. In addition, all items
containing a ticked check box with the annotation “document as variance”, will have a tick in the ‘Variance’
column. This allows for all variances to be easily identified and correlated with the additional information
noted on pages 2 and 3 of the checklist.
PREOPERATIVE CHECKLIST
Identification of patient or substitute decision-maker
Everybody has the right to make decisions that affect their life. An adult (person 18 years and over) can
give their consent to or refuse medical treatment if they understand the doctor's information about the
treatment and can make reasonable choices based on the information.
When a person does not have capacity to make their own decisions, they may need a formal decision-
maker appointed. A formal decision-maker can make decisions on behalf of a person about all aspects of
their life. If a person has appointed an attorney under an Enduring Power of Attorney, this person would
take on the role as a formal decision-maker. More than one attorney may be appointed to manage
personal, health and financial matters. Only the attorney appointed for health matters is able to make
health care related decisions. Further information is available here.
Where no attorney is appointed and where the person may be at risk of harm, an application can be made
to the Queensland Civil and Administrative Tribunal (QCAT) to have a formal decision-maker appointed.
Further information is available here.
In Queensland, anyone under the age of 18 is considered a minor. References to children usually mean
younger children who are likely to lack the maturity and understanding to make important decisions for
themselves. Older or more mature children who may have capacity to make decisions about health care
are often referred to as ‘young persons'. Although the patient is a child/young person, the patient may be
capable of giving informed consent and having sufficient maturity, understanding and intelligence to enable
them to fully understand the nature, consequences and risks of the proposed procedure / treatment /
investigation / examination and the consequences of non-treatment – ‘Gillick competence’ (Gillick v West
Norfolk and Wisbech Area Health Authority [1986] AC 112).
When a child or young person under the age of 18 years does not have capacity to consent, consent is
obtained from a parent or other person with parental responsibility except in specific situations. Persons
with parental responsibility have a responsibility to consent to health care that is in the best interests of
the child or young person.
The Guide to Informed Decision-making in Health Care documents the broadening approach to informed
patient decision-making in Queensland Health and is intended to be contemporaneous with and reflect the
national and international ethical, medico-legal and service delivery environment as it evolves and relates
to Queensland. It guides good clinical practice within the prevailing legal framework in how to implement
the principles of informed decision-making in clinical practice.
Tick ‘Patient’, ‘Substitute decision-maker’ or ‘Other’ (eg. carer, close friend, family member) to identify the
person providing the information. Document their name and relationship to the patient in the space
provided on the checklist.
1. Patient or substitute decision-maker to state full name and DOB and confirm full
name, DOB and URN match ID band and medical record
Ensure patient identifiers are consistent with the patient’s medical record. Check for correct spelling of
names, date of birth and UR number. If the identification band is not present or is incorrect, a new
identification band must be applied, and the patient identifiers checked with the escorting clinician and the
patient (if applicable). Ensure the identification band is not placed on an intended surgical site limb and be
mindful of possible intravenous access requirements.
3
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
Tick ‘Yes’ to indicate that the patient’s identity is confirmed. Tick ‘No’ to indicate that the patient’s identity
cannot be confirmed (i.e. emergency situations, red blankets etc.) and provide information in the relevant
section on page 2 of the checklist. Document the patient’s preferred name.
2. Legal documentation (EPOA, ARP, AHD, other)
The existence of a health plan is recorded on the Preoperative Checklist.
Advance care planning is a person-centred process of planning for future health and personal care that
reflects the person's goals, values, beliefs and preferences.
Enduring Power of Attorney (EPOA) allows a patient to appoint someone they trust (an ‘attorney’) to make
decisions during their lifetime and continues if they lose capacity to make decisions themselves. Only the
attorney appointed for health matters is able to make health care related decisions.
An Acute Resuscitation Plan (ARP) is a medical order initiated and completed by a medical officer through
the completion of the ARP form SW065 Acute Resuscitation plan.
An Advance Health Directive (AHD) is a document that allows a patient to make decisions about their
healthcare and can be used at a future time if they become unwell and are unable to make decisions.
Tick ‘Yes’ to indicate the patient has legal documentation and provide detail in the relevant section on
page 2 of the checklist. Tick ‘No’ to indicate the patient does not have legal documentation.
3. Valid procedural consent form completed
Informed consent is an integral component of the provision of quality, patient-centred healthcare. The
Queensland Health suite of informed consent documents support the rights of patients and their substitute
decision-makers to:
• Receive, understand and confirm their understanding of information about their health care
• Make informed decisions, including declining treatment or withdrawing consent at any time
• Have their decisions respected.
Every effort must be made to ensure a valid procedural consent form has been completed before the
patient is transferred to the operating theatre suite
9
.
A consent form remains valid for up to 12 months.
Tick ‘Yes’ to indicate consent has been completed and is valid. Tick ‘No’ to indicate that there is not a valid
consent form and provide detail in the relevant section on page 2 of the checklist. Notify the treating
medical officer or relevant clinician that the consent has not been completed.
4. Patient or substitute decision-maker to state procedure in own words and confirm
procedure stated corresponds with signed consent form
Clinicians should ask the patient or substitute decision-maker to articulate their knowledge of the
intended procedure in their own words. The clinician must ensure that this description correlates with the
surgical procedure noted on the procedural consent form and what has been booked on the operating
lists (to prevent cognitive bias). Escalate any discrepancies to the treating medical officer. The non-
delegable responsibility for providing necessary information and advice to the patient or substitute
decision-maker remains the responsibility of the treating medical officer
9
.
Tick ‘Yes’ to indicate that the patient or substitute decision-maker has described the procedure that is to
be undertaken in their own words and document the words spoken in the space provided. Tick ‘No’ to
indicate that the patient or substitute decision-maker cannot describe the procedure that is to be
undertaken in their own words and provide detail in the relevant section on page 2 of the checklist. Tick
‘Team contacted’ on page 2 of the checklist to indicate the treating medical officer has been informed.
4
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
5. Intended surgical site marked by surgeon
Internationally the failure to correctly identify patients and relate this information to an intended clinical
intervention continues to result in wrong person or wrong site procedures, medication errors, transfusion
errors and diagnostic testing errors
10
.
Clinicians are required to check that the surgical site has been marked by the surgeon. Certain surgeries
may not require marking given the anatomical location (eg. dental, endoscopy/colonoscopy, urogenital,
colorectal, perineal or laparoscopic surgery).
Tick ‘Yes’ to indicate that the surgical site has been marked by the surgeon. Tick ‘No’ to indicate that the
surgical site has not been marked and provide detail in the relevant section of page 2 of the checklist.
Verbalise that the site is not marked to the relevant clinician as part of the clinical handover and tick ‘Team
contacted’ in the variance section on page 2 of the checklist.
6. X-rays, medical imaging, PACS
Relevant x-rays or scans required for the intended surgery may either be available as digital images on
Queensland Health enterprise Picture Archive and Communication System (PACS) or as hard copies in
the form of compact discs (CDs) or hard films. Ensure all hard copies are sent with the patient to theatre.
Tick ‘Yes’ to indicate X-rays, medical imaging or PACS are available and provide detail in the relevant
section on page 2 of the checklist. Ensure all hard copies (eg. X-ray films or CDs) accompany the patient
to theatre. Tick ‘No’ to indicate X-rays, medical imaging or PACS are not available or required.
ALERTS
Alerts are potential risks that may impact on both patient care and the safety of staff involved in the patient’s
care. Once an alert eg. allergy and/or Adverse Drug Reaction (ADR) is documented and remains active,
it is incumbent on those delivering care to ensure that measures are put in place to control or reduce the
risks.
7. Allergy or Adverse Drug Reaction
Allergies and ADRs are very common, with around 1 in 5 people in Australia experiencing an allergy or
ADR during their lives. Allergies occur when a person’s immune system reacts to substances in the
environment that are harmless for most people. These reactions can be mild to moderate with a small
number of people experiencing a severe allergic reaction called anaphylaxis which is life threatening.
Common allergens include medications, latex, foods (including shellfish, fish), topical substances (eg.
iodine, dressing adhesives, lotions, metal) and environmental allergens (eg. insect bites, bee stings,
pollen).
All allergies and ADRs should be recorded as even mild reactions can impact on patient compliance with
medication use. Re-exposure to a drug or drug group to which the patient has had a previous adverse or
allergic reaction is one of the most common preventable medication incidents.
Tick ‘Yes’ to indicate the patient has allergies or ADRs and provide detail in the relevant section on page
2 of the checklist. Tick ‘Nil known’ to indicate the patient is not aware of any allergies or ADRs.
8. Infection precautions
Communication of infection risk to theatre staff is important to allow for preparation prior to receiving the
patient in the operating theatre. The floor coordinator should be notified of all patients with a current
infection as well as patients known to be colonized with resistant organisms. Early notification upon
identification of an infection risk will assist in determining the order of the theatre list, the level of theatre
preparation and of staffing Personal Protective Equipment (PPE) required.
5
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
Tick ‘Yes’ to indicate that current infection or colonisation with resistant organisms have been identified
and provide detail in the relevant section on page 2 of the checklist. Ensure early communication of any
infection risk to theatre staff. Tick ‘Operating theatre contacted’ to confirm communication has occurred.
Tick ‘No’ to indicate current infection or colonisation with resistant organisms have not been identified.
9. Cytotoxic medication administered in the last 7 days
Cytotoxic medications have carcinogenic, mutagenic and teratogenic properties and are considered to be
hazardous substances as per the Approved Criteria For Classifying Hazardous Substances [NOHSC:1008
(2004)] 3rd edition. As such, spills of cytotoxics and waste contaminated with cytotoxic substances must
be appropriately managed to limit exposure to workers and others. Waste from cytotoxic medications may
be in solid or liquid form. Cytotoxic medications and their metabolites are primarily excreted from the
patient via urine or faeces. Excretion rates vary therefore it is recommended that safety precautions with
respect to body fluids be adopted for at least seven days after the administration of the treatment
11
.
Refer to EVIQ, chemo specific chart, ieMR etc. to ascertain whether or not a cytotoxic medication has
been administered.
Tick ‘Yes’ to indicate that cytotoxic medications have been administered in the last 7 days and provide
detail in the relevant section on page 2 of the checklist. Tick ‘No’ to indicate that cytotoxic medications
have not been administered in the last 7 days.
10. Anticoagulation, antiplatelet agent, thrombolytics or any complementary medicines
The perioperative management of patients on medications that have potential blood thinning properties
can be challenging and decision-making should involve assessing risks of thromboembolism, major
bleeding and the associated consequences. Clinicians are required to check to ensure the VTE
assessment is completed within 12 hours of the patient’s admission. Patients should be assessed on a
case-by-case basis in consultation with the surgeon/proceduralist, treating physician and anaesthetist.
Further information is available here.
Examples of medications that increase the risk of bleeding include anticoagulants, antiplatelet agents,
thrombolytics or any complementary medicines eg. fish oil, turmeric. A list can be found here.
Check to ensure the perioperative medication advice has been followed. Tick ‘Yes’ to indicate that
anticoagulants, antiplatelet agents, thrombolytics or any other complementary medicines have been
administered in the last 7 days and provide detail in the section provided on page 2 of the checklist. Tick
‘No’ to indicate that anticoagulants, antiplatelet agents, thrombolytics or any other complementary
medicines have not been administered in the last 7 days.
11. Patient refuses blood products
There is always potential for surgical procedures to cause unexpected bleeding. Patients must be asked
if they have any objections to receiving blood, blood products or blood derivatives including albumin.
Should the patient refuse any of these, the relevant informed refusal document should be completed prior
to surgery. For surgeries where perioperative blood transfusion may be likely, the treating team should
complete the Fresh Blood and Blood Products Transfusion Consent form or other relevant transfusion
consent forms (available here), prior to transfer to theatre. In the absence of a Queensland Health consent
form, the details of the conversion between the patient and health practitioner, is considered to be part of
the care given to the patient and as such, can be recorded in the patient’s clinical record. Further
information is available here.
Tick ‘Yes’ to indicate the patient refuses blood products and provide detail in the section provided on page
2 of the checklist. Ensure the treating medical officer completes a written informed refusal document and
tick ‘Team contacted’ in the section provided. Tick ‘No’ to indicate that the patient does not object to
receiving blood products.
6
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
12. Pregnant
Beta Human Chorionic Gonadotropin (HCG) is a hormone produced by the placenta during pregnancy
and is typically detected in the blood. A Beta HCG test is a blood test used to diagnose pregnancy and
usually becomes positive around the time of the first missed period.
When determining whether or not the patient may be pregnant, the following dialogue is recommended:
‘We see many people with a lot of different body types so for safety reasons we ask everyone “Are you
sexually active? Is there any chance you may be pregnant?”.
Further information is available on the Children’s Health Queensland Hospital and Health Service website
here.
Tick ‘Yes’ to indicate the patient is pregnant. Tick ‘No’ to indicate that the patient is not pregnant. Tick
‘Suspected or unknown’ to indicate uncertainty with regards to pregnancy and document as a variance on
Page 2 of the checklist. Ensure a Beta HCG urine test is conducted and complete the section provided.
13. Diabetic
Diabetes affects 10–15% of the surgical population and patients with diabetes undergoing surgery have
greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical
patient with diabetes focuses on thorough pre-operative assessment and optimisation of their diabetes.
12
As patients are fasted prior to surgery, most diabetic medications will be adjusted perioperatively to reduce
the risk of hypoglycaemia. Patients on sodium-glucose co-transporter-2 inhibitor (SGLT2i) medications are
at risk of developing severe acidosis during the perioperative period and blood ketone testing is particularly
important in these patients. These medications include dapagliflozin, empagliflozin and ertugliflozin.
Further information is available here. Insulin requiring patients must have their insulin requirements met
during the perioperative period to facilitate the cellular uptake of glucose and reduce the risk of
ketoacidosis.
Tick ‘Yes’ to indicate the patient is diabetic and provide detail in the section provided on page 2 of the
checklist. Ensure the completed diabetic chart accompanies the patient to theatre. Tick ‘No’ to indicate the
patient is not diabetic.
14. Skin assessment
Hospital-acquired pressure injuries lead to complications such as increased pain, increased bed days, re-
admissions, multiple surgical interventions, possible disfigurement, decreased quality of life, increased
health care cost and mortality
13
. In the elderly, many skin changes due to loss of elasticity and
subcutaneous tissue added to decreased circulation and lack of fat pads on bony prominences increase
the potential for skin problems during surgical procedures.
The process of examining the entire body surface for abnormalities requires looking at and touching skin
from head to toe and front to back. This skin assessment captures the patient’s general skin integrity,
based on careful inspection and palpation of the skin to identify existing skin conditions (i.e. cuts,
abrasions, bruises, rash, pimples, ecchymoses, burns, scars, pressure injuries etc.). Documenting your
skin integrity findings on the pressure risk assessment tool assists the effective preparation of the patient
for surgery and the necessary treatment required post-surgery.
Tick ‘Intact’ to indicate there are no issues pertaining to skin integrity. Tick ‘Not intact’ to indicate that
issues pertaining to skin integrity have been identified and provide detail in the section provided on page
2 of the checklist. If an assessment has not been performed, tick ‘Not assessed’ and provide detail in the
section provided on page 2 of the checklist.
Pressure risk assessment tool completed
Pressure injuries can occur in any patient, any time and at any age. Pressure injuries are a major
contributor to the care requirements of patients within the healthcare sector and are mostly preventable.
7
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
To achieve a reduction in the prevalence and incidence of pressure injuries requires early identification of
those at risk; implementation of timely and appropriate prevention and management strategies; education
and information sharing.
Queensland Health pressure injury prevention and management practice is based on the Prevention and
Treatment of Pressure Ulcer/Injuries Clinical Practice Guideline – The International Guideline 2019.
As indicated on the Adult Pressure Injury Risk Assessment Tool, the skin should be assessed for any
signs of erythema, blanching response, localised heat, oedema, induration and skin breakdown (including
observation for any skin damage related to medical devices, plaster casts). Further information for
healthcare staff, patients and carers is available here.
Tick ‘Yes’ to indicate that the Pressure Injury Risk Assessment Tool has been completed. Notify the
clinician of any concerns during handover. Tick ‘No’ to indicate the Pressure Injury Risk Assessment Tool
has not been completed and provide detail in the section provided on page 2 of the checklist.
15. Other alerts
This section of the checklist is used to document any other concerns that should be brought to the
attention of the perioperative team. These may include but are not limited to falls risks, language barriers
and aberrant behaviours.
Falls
Fall-related injury is one of the leading causes of hospital-acquired morbidity and mortality in older
Australians, and leads to pain, bruising and lacerations and fractures
14
. Falls in hospital which cause
harm, such as intracranial injury, fractured neck of femur and other fractures, also prolong length of stay.
Patients experiencing one of these falls remain in hospital for 18.8 days longer on average than patients
who don’t experience this hospital-acquired complication
15
. More information about hospital acquired
complications for falls can be found here.
Falls in hospital are not inevitable for any patient and prevention is an integral part of a patient’s
comprehensive care plan that involves collaborative care and communication in partnership with patients,
carers, families and members of the healthcare team. Every staff member has a part to play in fall
prevention within and beyond our hospital and health services. Further information is available here.
Interpreter
A certified interpreter should be engaged when the information to be communicated is significant for health
and/or health outcomes, the person has a Queensland interpreter card, the person requests an interpreter,
or the person’s English skills are assessed to be inadequate for the situation.
Working with certified interpreters ensures that you communicate through a trained, bilingual person, who
is guided by a code of ethics and respects the confidentiality of the person, is impartial, accountable and
strives for accuracy. Working with a certified interpreter should not only meet the client’s needs, but also
your duty of care obligations to understand and be understood by people receiving a health service. Health
services must consider the potential legal consequences of adverse outcomes when using unaccredited
people to ‘interpret’ if an accredited interpreter is available. Guidelines and resources are available here.
Aggression
Whilst there are a number of key healthcare hazards in the healthcare and social assistance industry
which can impact the health, safety and wellbeing of workers, exposure to work-related violence and
aggression is a particular concern. Healthcare workers may experience violence and aggression from
patients and residents, visiting friends and family and bystanders. Exposure to occupational violence has
the potential to cause or contribute to the development of both physical and psychological injury to
workers. Further information is available here.
Tick ‘Yes’ to indicate other alerts (eg. falls, interpreter, aggression) are a consideration in the management
of the patient and provide detail in the section provided on page 2 of the checklist. Tick ‘No’ to indicate
other alerts are not a consideration in the management of the patient.
8
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
16. Fasted
The aim of fasting prior to anaesthesia or sedation for a surgical or medical procedure is to decrease the
risk of perioperative regurgitation, which may result in aspiration. This may be associated with chemical
pneumonitis, bacterial pneumonia or airway obstruction depending upon whether foreign material (food)
and/or gastro-intestinal fluids (gastric acid, bile or other bowel contents) have been aspirated into the
lungs. Such patients may require treatment in critical care units
16
.
Clear fluids are regarded as water, carbohydrate rich fluids specifically developed for perioperative use,
pulp free fruit juice, clear cordial, black tea and coffee. It excludes fluids containing particulate matter,
soluble fibre, milk-based drinks and jelly
17
.
For adults having an elective procedure, limited solid food may be taken up to six hours prior to
anaesthesia and clear fluids may be taken up to two hours prior to anaesthesia. ANZCA (PS07), Guideline
on pre-anaesthesia consultation and patient preparation is available here.
The Children’s Health Queensland Pre-operative and Pre-procedural Fasting Guidelines serves as a guide
to all staff preparing children or providing information to children / parents / carers prior to general
anaesthesia, major local anaesthetic blocks or non-conscious sedation. It also contains a quick reference
guide with timeframes namely one hour for clear, non-carbonated fluids, four hours for breast milk (no
thickeners) and six hours for everything else with the exception of babies under six months of age who
may have infant formula (no thickeners) until four hours pre-procedure.
Tick ‘Yes’ to indicate the patient has fasted and complete the date and time of last intake. Tick ‘No’ to
indicate the patient has not fasted and provide detail in the section provided on page 3 of the checklist.
It is important to make the theatre team aware of any patients who have not fasted for the recommended
timeframes. Tick the check box provided to indicate that the operating theatre team has been contacted.
17. Pre-medication administered and other usual medication withheld
All nursing/midwifery, medical and pharmacy staff are authorised to access and use patient medication
charts. Use of the National Inpatient Medication Chart (NIMC) is a mandatory requirement for non-digital
health service organisations seeking accreditation against National Safety and Quality Health Service
Standards (NSQHS) Standard 4 Medication Safety (Australian Commission on Safety and Quality in
Health Care, 2017).
•
All authorised prescribers must order medicines for inpatients in accordance with legislative
requirements as documented in the Health (Drugs and Poisons) Regulation 1996. Further information
in relation to regulation, standards and extended practice authorities is available here.
•
The medication chart is to be completed for all admitted patients where an electronic prescribing
system is not in use.
•
All medicines should be reviewed regularly to identify potential interactions and to discontinue
medicines that are no longer required.
•
Specific medication charts are required for specialised medicines such as insulin, intravenous fluids,
parenteral cytotoxic and immunosuppressive agents, epidural and regional infusions, palliative care
and patient controlled analgesia
18
.
Tick ‘Yes’ to indicate pre-medication has been administered and provide detail in the section provided on
page 3 of the checklist. Tick ‘No’ to indicate pre-medication has not been administered. Refer to the NIMC
during handover. Tick ‘Yes’ to indicate that other usual medication has been withheld and provide detail
in the section provided on page 3 of the checklist. Tick ‘No’ to indicate that other medication has not been
withheld. Refer to the source document for a list of the patient’s medications (Adult Integrated Pre-
procedure Screening Tool, GP summary etc.).
18. Existing implants, prosthesis
Identify whether the patient has any existing implants and / or prosthetics as these may have
implications during surgery, particularly with the use of diathermy. Examples of implants include
orthopaedic metalware (pins, plates, screws), pacemakers, intra-ocular lenses and portacaths.
9
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
Tick ‘Yes’ to indicate the patient has existing implants and / or prostheses and provide detail in the section
provided on page 3 of the checklist including the nature and location of each implant / prosthesis. Tick ‘No’
to indicate the patient has no existing implants and/or prostheses.
19. Caps, crowns, loose teeth, braces or dentures
Dental injury in anaesthesia represents up to half of all anaesthetic claims. Most at risk are children, the
elderly and any patients with crowns, veneers and bridgework, periodontal disease, protruding or
isolated teeth and conditions that lead to airway obstruction or difficult intubation. It is important to
identify and document any dental prosthetics. Further information is available here.
Full and partial dentures are to remain in-situ when transferred to theatre unless medically directed. Any
dentures removed in theatre must be placed in a denture container labelled with a patient identification
sticker and accompany the patient on their journey through and out of the perioperative suite.
Tick ‘Yes; to indicate the patient has caps, crowns, loose teeth, braces or dentures and provide detail in
the section provided on page 3 of the checklist. Tick ‘No’ to indicate the patient does not have caps,
crowns, loose teeth, braces or dentures.
20. Personal aids, items
Some patients may require aids to improve their vision or hearing and other patients may need items of
familiarity or comfort to accompany them through their perioperative journey. It is important to note whether
these items have been removed prior to the patient being transferred to theatre or left in-situ. All contact
lenses should be removed prior to transfer to the theatre suite. Glasses, hearing aids and items of comfort
usually accompany the patient. All personal items must be labelled or placed in a correctly labelled
container.
Tick ‘Yes’ to indicate the patient has personal aids and / or items and provide detail in the section provided
on page 3 of the checklist. Tick ‘No’ to indicate the patient does not have any personal aids or items.
21. Preparation
Ensure the patient has removed the necessary clothing and underwear and is wearing appropriate theatre
attire (short-sleeved hospital gown, disposable underpants, disposable beret or theatre cap). Children may
present in clean cotton pyjamas provided by the hospital or wear their own if preferred.
Jewellery, body piercings, hair ties and hair pins can cause patient injury in theatre, either from mechanical
trauma or with use of diathermy. Ideally these items should be removed prior to admission to the operating
theatre suite. Any items left in-situ should be taped (if possible) and documented.
Make-up, nail polish and false fingernails can interfere with monitoring and clinical detection of
deterioration. Check that make-up, nail polish and false fingernails have been removed and if necessary,
assist the patient to remove them. This should be done before transfer to the operating theatre suite.
Discuss preoperative patient skin antisepsis with the patient and assess the operative site for satisfactory
hair removal (if necessary). Refer to the Australian College of Perioperative Nurses (ACORN) Standards
for Perioperative Nursing in Australia.
Given that patient preparation varies according to surgical procedure and individual surgeon preference,
please follow local workplace requirements to ensure adequate patient preparation.
Bowel preparation
Bowel preparation usually involves modification of diet, ingestion of a laxative or bowel preparation
medication and an increase in fluid intake, with an aim to empty and clean the bowel prior to colonoscopy
or surgery. This facilitates visualisation of the colon and detection of abnormal growths or areas which
may be cancerous. Poor bowel preparation may lead to missed lesions and may result in the procedure
being abandoned to be repeated at a later date. Bowel preparation may be used prior to certain bowel
surgery, though this has fallen out of favour as part of the enhanced recovery programs.
10
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
Bowel preparation would be considered satisfactory if the patient describes their return as a clear yellow
fluid (similar to urine) and without any solid matter present.
Anti-embolic devices
Hospitalised patients are at increased risk of developing deep vein thrombosis (DVT) in the lower limb and
pelvic veins, on a background of prolonged immobilisation associated with their medical or surgical illness.
Patients with DVT are at increased risk of developing a pulmonary embolism. The use of graduated
compression stockings in hospitalised patients has been proposed to decrease the risk of DVT
19
.
The Adult VTE risk assessment tool should be completed and unless the procedure is under local
anaesthesia without limitation of mobility, compression stockings should be applied.
Tick the relevant boxes provided in the checklist. If the boxes checked indicate documentation of a
variance is required and / or if the boxes provided are not relevant to the patient or case being undertaken,
provide detail in the relevant section provided on page 3 of the checklist.
22. Patient continent of urine
Certain intra-abdominal procedures require the patient to have emptied their bladder prior to surgery to
facilitate surgical access and reduce the risk of bladder injury. In general, the risk of urine retention may
be increased in the elderly, prostate enlargement, severe constipation, spinal cord injury, neurogenic
bladder conditions or tumours. If a patient is unable to urinate, it may be necessary to pass a catheter
preoperatively. Clinicians should document the time that the patient last self-voided or alternatively
document the presence of an indwelling catheter or use of incontinence aids.
Tick ‘Yes’ to indicate the patient has passed urine. Tick ‘No’ to indicate the patient has not passed urine
and document as a variance on page 3 of the checklist. Provide the last void time in the space provided
on the checklist. Tick ‘IDC in-situ’ to indicate that an indwelling catheter is in use and provide detail on
page 3 of the checklist.
23. Relevant documentation
Check that relevant documentation is available and matches the identification of the patient eg. medical
record, fluid order sheet, medication chart, fluid balance chart, diabetic chart (if required), identification
labels (minimum of three pages), ECG (if required), observation form (Q-ADDS, CEWT, MEWT).
Tick ‘Yes’ to indicate that relevant documentation (eg. medical record, medical chart, fluid order sheet,
fluid balance chart, diabetic chart, 3 sheets of patient labels, observation sheet, ECG) are present. Tick
‘No’ to indicate necessary documentation is not present and provide detail in the section provided on page
3 of the checklist.
24. Patient or substitute decision-maker agrees to clinicians discussing the procedure
with the nominated support person
Patients presenting for day surgery need to be accompanied by a responsible adult on discharge from the
hospital. Given the effects of recent anaesthetics on a patient’s ability to recall information, intra-operative
events and post-operative instructions such as wound dressing requirements, medication prescriptions
and follow up appointments may need to be discussed with a support person.
Patients may not want certain information disclosed to a third party and therefore clinicians should clarify
the needs, expectations and nature of information to be disclosed to support persons with their patients.
Tick ‘Yes’ to indicate the patient or substitute decision-maker agrees to clinicians discussing the procedure
with the nominated support person. Document the name of the support person and their contact phone
number. Tick ‘No’ to indicate the patient or substitute decision-maker does not agree to clinicians
discussing the procedure with the nominated support person and provide detail in the section provided on
page 3 of the checklist.
11
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
REFERENCES
1. Joint Commission on Accreditation of Healthcare Organizations. Sentinel event statistics.
http://www.jointcommission.org/SentinelEvents/Statistics. Accessed October 14, 2007.
2. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical
mishaps. Acad Med. 2004;79(2):186-194.
3. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three
teaching hospitals. Surgery. 2003;133(6):614-621.
4. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142(5):352-358.
5. 1. Laine C, Williams SV, Wilson JF. In the clinic. Preoperative evaluation. Ann Intern Med. 2009;151(1):2–
16. [PubMed] [Google Scholar]
6. Murphy, Katherine; Walker, Kim; Duff, Jed; and Williams, Robyn (2016) "The collaborative
development of a pre-operative checklist: An e-Delphi study," Journal of Perioperative Nursing: Vol.
29 : Iss. 1 , Article 3. Available at: https://doi.org/10.26550/2209-1092.1002 .
7. Haynes AB, Weiser TG, Berry WR, et al. The Safe Surgery Saves Lives Study Group A surgical safety
checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–
499. [PubMed] [Google Scholar]
8. Queensland Health (2013), Guideline: Surgical Safety Checklist
<https://qheps.health.qld.gov.au/__data/assets/pdf_file/0036/695592/surgical-safe-guide.pdf >
9. ACORN (2017), Volume 30, Issue 1 Surgical Consent and the importance of a substitute decision-maker:
A case study
10. Australian Commission on Safety and Quality in Healthcare (2008), Ensuring Correct Patient, Correct
Site, Correct Procedure Protocol for Surgery: Review of implementation and proposals for action
<Microsoft Word - Review of correct site protocol FINAL 16 Oct 2008 (safetyandquality.gov.au)>
11.
Cytotoxic spills and waste management - Guidance note (health.qld.gov.au)
12. Association of Anaesthetists (2015), Peri-operative management of the surgical patient with diabetes, <
Peri-operative management of the surgical patient with diabetes | Association of Anaesthetists>.
13. Australian Commission on Safety and Quality in Health Care. 2018. Hospital-Acquired Complication 1
pressure injury pdf
14. Australian Commission on Safety and Quality in Health Care. 2018. Hospital-Acquired Complication 2.
Falls resulting in fracture or intracranial injury
https://www.safetyandquality.gov.au/sites/default/files/migrated/Falls-resulting-in-fracture-of-intracranial-
injury-detailed-fact-sheet.pdf
15. Independent Hospital Pricing Authority (AU). Activity Based Funding Admitted Patient Care 2015-16,
acute admitted episodes, excluding same day)
16. AORN Preoperative Assessment: Case Study < Preoperative-Assessment (1).pdf >
17. ANZCA, PS07 (2017), Guideline on pre-anaesthesia consultation and patient preparation, <
https://www.anzca.edu.au/getattachment/d2c8053c-7e76-410e-93ce-3f9a56ffd881/PS07-Guideline-on-
pre-anaesthesia-consultation-and-patient-preparation >
18.
National Inpatient Medication Chart SW001, v13.00 – User Guide (April 2021)
<
https://qheps.health.qld.gov.au/__data/assets/pdf_file/0044/2639969/nimc-userguide.pdf >
19. Cochrane Library (2018) Nov 3. doi: 10.1002/14651858.CD001484.pub4, Graduated compression
stockings for prevention of deep vein thrombosis < Graduated compression stockings for prevention of
deep vein thrombosis (nih.gov)>
RELATED STANDARDS
•
Australian College of Perioperative Nurses Ltd. (2020). Standards for Perioperative Nursing in
Australia, Volume 1 Clinical Standards, 16th edition. Adelaide, South Australia – Documentation and
patient information management.
•
Australian College of Perioperative Nurses Ltd. (2020). Standards for Perioperative Nursing in
Australia, Volume 1 Clinical Standards, 16th edition. Adelaide, South Australia – Preoperative patient
skin antisepsis.
•
NSQHS v2 — Standard 5 — Comprehensive care
•
NSQHS v2 — Standard 6 — Communicating for safety
CONTACT
For further information please contact:
SWAPNET@health.qld.gov.au or Phone: (07) 3328 9164
12
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
PREOPERATIVE CHECKLIST QUICK REFERENCE GUIDE
Appendix 1
Item
Question
Completing the checklist
Information provided by:
Tick ‘Patient’, ‘Substitute decision-maker’ or ‘Other’ (eg. carer, close friend, family
member) to identify the person providing the information. Document their name and
relationship to the patient in the space provided on the checklist
1
Patient or substitute
decision-maker to state full
name and DOB and confirm
full name, DOB and URN
match ID band and medical
record
Tick ‘Yes’ to indicate that the patient’s identity is confirmed. Tick ‘No’ to indicate that the
patient’s identity cannot be confirmed (eg. emergency situations, red blankets etc.) and
provide information in the relevant section on page 2 of the checklist. Document the
patient’s preferred name.
2
Legal documentation
(EPOA, ARP, AHD, other)
Tick ‘Yes’ to indicate the patient has legal documentation and provide detail in the
relevant section on page 2 of the checklist. Tick ‘No’ to indicate the patient does not
have legal documentation.
3
Valid procedural consent
form completed
Tick ‘Yes’ to indicate consent has been completed and is valid. Tick ‘No’ to indicate that
there is not a valid consent form and provide detail in the relevant section on page 2 of
the checklist. Notify the treating medical officer or relevant clinician that the consent has
not been completed.
4
Patient or substitute
decision-maker to state
procedure in own words
and confirm procedure
stated corresponds with
signed consent form
Tick ‘Yes’ to indicate that the patient or substitute decision-maker has described the
procedure that is to be undertaken in their own words and document the words spoken
in the space provided. Tick ‘No’ to indicate that the patient or substitute decision-maker
cannot describe the procedure that is to be undertaken in their own words and provide
detail in the relevant section on page 2 of the checklist. Tick ‘Team contacted’ on page 2
of the checklist to indicate the treating medical officer has been informed.
5
Intended surgical site
marked by surgeon
Tick ‘Yes’ to indicate that the surgical site has been marked by the surgeon. Tick ‘No’ to
indicate that the surgical site has not been marked and provide detail in the relevant
section of page 2 of the checklist. Verbalise that the site is not marked to the relevant
clinician as part of the clinical handover and tick ‘Team contacted’ in the variance
section on page 2 of the checklist
6
X-rays, medical imaging,
PACS
Tick ‘Yes’ to indicate X-rays, medical imaging or PACS are available and provide detail
in the relevant section on page 2 of the checklist. Ensure all hard copies (eg. X-ray films
or CDs) accompany the patient to theatre. Tick ‘No’ to indicate X-rays, medical imaging
or PACS are not available or required.
7
Allergy or Adverse Drug
Reaction
Tick ‘Yes’ to indicate the patient has allergies or ADRs and provide detail in the relevant
section on page 2 of the checklist. Tick ‘Nil known’ to indicate the patient is not aware of
any allergies or ADRs.
8
Infection precautions
Tick ‘Yes’ to indicate that current infection or colonisation with resistant organisms have
been identified and provide detail in the relevant section on page 2 of the checklist.
Ensure early communication of any infection risk to theatre staff. Tick ‘Operating theatre
contacted’ to confirm communication has occurred. Tick ‘No’ to indicate current infection
or colonisation with resistant organisms have not been identified.
9
Cytotoxic mediations
administered in the last 7
days
Tick ‘Yes’ to indicate that cytotoxic medications have been administered in the last 7
days and provide detail in the relevant section on page 2 of the checklist. Tick ‘No’ to
indicate that cytotoxic medications have not been administered in the last 7 days.
10
Anticoagulant, antiplatelet
agent, thrombolytics or any
complementary medicines
Check to ensure the perioperative medication advice has been followed. Tick ‘Yes’ to
indicate that anticoagulants, antiplatelet agents, thrombolytics or any other
complementary medicines have been administered in the last 7 days and provide detail
in the section provided on page 2 of the checklist. Tick ‘No’ to indicate that
anticoagulants, antiplatelet agents, thrombolytics or any other complementary medicines
have not been administered in the last 7 days.
11
Patient refuses blood
products
Tick ‘Yes’ to indicate the patient refuses blood products and provide detail in the section
provided on page 2 of the checklist. Ensure the treating medical officer completes a
written informed refusal document and tick ‘Team contacted’ in the section provided.
Tick ‘No’ to indicate that the patient does not object to receiving blood products.
12
Pregnant
Tick ‘Yes’ to indicate the patient is pregnant. Tick ‘No’ to indicate that the patient is not
pregnant. Tick ‘Suspected or unknown’ to indicate uncertainty with regards to pregnancy
and document as a variance on Page 2 of the checklist. Ensure a Beta HCG urine test is
conducted and complete the section provided.
13
Preoperative Checklist Context_v1.0 Author: SWAPNET@health.qld.gov.au
13
Diabetic
Tick ‘Yes’ to indicate the patient is diabetic and provide detail in the section provided on
page 2 of the checklist. Ensure the completed diabetic chart accompanies the patient to
theatre. Tick ‘No’ to indicate the patient is not diabetic.
14
Skin assessment
Tick ‘Intact’ to indicate there are not issues pertaining to skin integrity. Tick ‘Not intact’ to
indicate that issues pertaining to skin integrity have been identified and provide detail in
the section provided on page 2 of the checklist. If an assessment has not been
performed, tick ‘Not assessed’ and provide detail in the section provided on page 2 of
the checklist.
Pressure risk assessment
tool completed
Tick ‘Yes’ to indicate that the Pressure Injury Risk Assessment Tool has been
completed. Notify the clinician of any concerns during handover. Tick ‘No’ to indicate the
Pressure Injury Risk Assessment Tool has not been completed and provide detail in the
section provided on page 2 of the checklist.
15
Other alerts
Tick ‘Yes’ to indicate other alerts (eg. falls, interpreter, aggression) are a consideration
in the management of the patient and provide detail in the section provided on page 2 of
the checklist. Tick ‘No’ to indicate other alerts are not a consideration in the
management of the patient.
16
Fasted
Tick ‘Yes’ to indicate the patient has fasted and complete the date and time of last
intake. Tick ‘No’ to indicate the patient has not fasted and provide detail in the section
provided on page 3 of the checklist. It is important to make the theatre team aware of
any patients who have not fasted for the recommended timeframes. Tick the check box
provided to indicate that the operating theatre team has been contacted
17
Pre-medication
administered and other
usual medication withheld
Tick ‘Yes’ to indicate pre-medication has been administered and provide detail in the
section provided on page 3 of the checklist. Tick ‘No’ to indicate pre-medication has not
been administered. Refer to the NIMC during handover.
Tick ‘Yes’ to indicate that other usual medication has been withheld and provide detail in
the section provided on page 3 of the checklist. Tick ‘No’ to indicate that other usual
medication has not been withheld.
Refer to the source document for a list of the patient’s medications (Adult Integrated
Pre-procedure Screening Tool, GP summary etc.)
18
Existing implants,
prostheses
Tick ‘Yes’ to indicate the patient has existing implants and / or prostheses and provide
detail in the section provided on page 3 of the checklist including the nature and location
of each implant / prosthesis. Tick ‘No’ to indicate the patient has no existing implants
and/or prostheses.
19
Caps, crowns, loose teeth,
braces or dentures
Tick ‘Yes; to indicate the patient has caps, crowns, loose teeth, braces or dentures and
provide detail in the section provided on page 3 of the checklist. Tick ‘No’ to indicate the
patient does not have caps, crowns, loose teeth, braces or dentures.
20
Personal aides, items
Tick ‘Yes’ to indicate the patient has personal aids and / or items and provide detail in
the section provided on page 3 of the checklist. Tick ‘No’ to indicate the patient does not
have any personal aids or items.
21
Preparation
Tick the relevant boxes provided in the checklist. If the boxes checked indicate
documentation of a variance is required and / or if the boxes provided are not relevant to
the patient or case being undertaken, provide detail in the relevant section provided on
page 3 of the checklist. Follow local workplace requirement to ensure adequate patient
preparation.
22
Patient continent of urine
Tick ‘Yes’ to indicate the patient has passed urine. Tick ‘No’ to indicate the patient has
not passed urine and document as a variance on page 3 of the checklist. Provide the
last void time in the space provided on the checklist. Tick ‘IDC in-situ’ to indicate that an
indwelling catheter is in use and provide detail on page 3 of the checklist.
23
Relevant documentation
Tick ‘Yes’ to indicate that relevant documentation (eg. medical record, medical chart,
fluid order sheet, fluid balance chart, diabetic chart, 3 sheets of patient labels,
observation sheet, ECG) are present. Tick ‘No’ to indicate necessary documentation is
not present and provide detail in the section provided on page 3 of the checklist.
24
Patient or substitute
decision-maker agrees to
clinicians discussing the
procedure with the
nominated support person
Tick ‘Yes’ to indicate the patient or substitute decision-maker agrees to clinicians
discussing the procedure with the nominated support person. Document the name of
the support person and their contact phone number. Tick ‘No’ to indicate the patient or
substitute decision-maker does not agree to clinicians discussing the procedure with the
nominated support person and provide detail in the section provided on page 3 of the
checklist.
