A simple, one-page, presurgery checklist can help a surgery center improve consistency, safety, and patient care and well-being.

The Plaza Medical Clinic in Van Nuys, CA, has developed a presurgery checklist to ensure each employee follows a consistent process when working with patients.

“The checklist is one page with everything you need,” says Edith Rabadan, facility administrator at Plaza Medical Center, which provides cosmetic surgery. “We start working with the checklist from the moment the patient says, ‘I want to have this surgery.’”

The checklist has improved process efficiency and patient satisfaction. “There are a lot of things to remember to do for the patient’s well-being and for the well-being of the medical center. This is where the surgical checklist is important,” Rabadan explains. “It serves as a checks and balance.”

The checklist was developed over time. Each time there was a discrepancy in presurgery processes or a problem emerged, the checklist was changed to address and prevent these issues, Rabadan says. “For example, on the day of a facelift surgery, the patient receives a mark where the incision would be,” she explains. “It is marked before the patient goes into the operating room, reducing risk of a wrong-site incision.”

After surgery, a patient might say the surgical site was not explained well to them before the procedure. Thus, patients are photographed before surgery to document the mark made to indicate the surgery incision site. “They might say they didn’t know the surgery site was along the hairline or behind the ear, but I knew it was verbally told to the patient,” Rabadan says. “We incorporated surgical site pictures after the doctor marks it. That avoids any legal discrepancy of ‘I was unaware or nobody told me about this.’” To ensure that employees routinely take pictures of incision sites, the task has been added to the checklist.

The presurgery checklist includes space for the surgery date, the patient’s name, the procedure, anesthesia type, and a variety of tasks and data that can be checked off as performed. For instance, one line is for the pre-op and assessment consultation, along with its date, Rabadan says.

The surgeon also discusses with the patient the incision site and size. Other checklist items include initial consultation, history and physical, surgical consent, anesthesia consent, smoker consent, and arbitration consent. “The AAAHC surveyor said he was really amazed that we even had Spanish consents,” Rabadan says. “We have HIPAA consent, pre-op consent, surgery consent, anesthesia consent, and a general consent.”

Some checklist items are only used for certain patients, including mammogram, breast implant sizing, order implants, breast lift measurements, eye exam, and lipo measurements. The eye exam is needed for patients who are undergoing eyelid surgery, Rabadan says. “Say a patient has eyelid surgery, and the patient’s vision is blurry after,” she offers. “The patient might come back a month later and say, ‘I didn’t have blurry vision before,’ so we need to document the patient’s eye abnormalities before surgery so we can say, ‘You had blurry vision before the surgery.’” For other procedures, a mammogram is needed. “We need to see the mammogram results if someone is having breast surgery,” Rabadan says. “If we put in breast implants, we want to make sure there are no lumps.”

The checklist also includes “medical clearance.” This is to ensure the center has obtained medical clearance from the patient’s primary provider before surgery. A doctor has to say the patient is in good health and is ready for surgery, she adds. “With any surgery, there will be some type of risk. When [patients] have elective surgery, there is time to get their blood work done and to make sure they’re in good health,” Rabadan says. “Especially when a surgery involves general anesthesia, we have a protocol where all surgical patients must have medical clearance. This helps us make sure that no one goes through a surgery without having a doctor see their medical history.”

The smoker consent is necessary for patients’ health and to reduce scarring. “If someone is a smoker, then the risk is raised a little,” Rabadan notes. “We ask patients to stop smoking for 10 days before surgery and 10 days after surgery. The checklist is a reminder for us to let them know to stop smoking.”

Additional checklist items include a pregnancy test, antibiotics and other pain medications, vital statistics taken on the day of surgery, discharge instructions, an operative report, and a post-op call. “The last thing done on this checklist is the post-op call,” Rabadan says. “An hour or two hours after a patient goes home, the nurse calls the patient to see how things are going and then documents that call on the checklist.”