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 < 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 Questionnaire

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