Common Procedure Checklists Pack

Common Procedure Checklists Pack

Purpose: provide concise, role-based checklists teams can adapt to local policy for four high-volume, higher-risk bedside procedures. Use these as a starting point—customize language, required equipment, monitoring, and documentation to match your facility, credentialing rules, and patient population.

How to use these checklists

• Assign roles clearly before the procedure (e.g., Proceduralist, Team Lead, Procedural Nurse, Medication Nurse, Documenter, Respiratory Therapist).
• Perform a structured Time Out (patient identity, procedure, site/side, consent, allergies, imaging/lines) with all present and speaking up encouraged.
• Adapt local infection-prevention elements (antiseptic choice, sterile barrier requirements) and sedation/monitoring policies.
• Document completion of checklist items in the medical record and keep a copy with the procedure note when required.
• If a checklist item cannot be completed, pause and resolve or escalate before proceeding.

Roles and recommended responsibilities

• Proceduralist — performs the procedure, ensures technique and site selection are appropriate.
• Team Lead — ensures readiness, coordinates the Time Out, and halts the procedure for safety concerns.
• Procedural Nurse — prepares sterile equipment, assists with sterile field, monitors supplies.
• Medication Nurse / Sedation Nurse — prepares and administers meds, monitors sedation level and vitals, documents meds given.
• Documenter — records key events, time stamps, specimen labeling, and the procedure note.
• Respiratory Therapist — supports airway management when relevant, confirms oxygenation/ventilation.

Central Line Insertion (Internal jugular/subclavian/femoral) — Checklist

Pre-procedure

• Indication and alternative considered documented and understood.
• Informed consent obtained and documented; if not able, legal basis recorded.
• Allergy check (especially chlorhexidine, latex, antibiotic agents).
• Coagulation and platelet status reviewed and acceptable per local guidelines.
• Appropriate imaging/ultrasound available and functional; operator competency confirmed.
• Full sterile barrier supplies ready: mask, cap, gown, sterile gloves, large drape, chlorhexidine prep, sterile ultrasound sheath, catheter kit, suture/securement, dressing.
• Resuscitation equipment available and functioning (oxygen, suction, intubation set if required).
• Monitoring in place (BP, HR, SpO2, continuous ECG) and baseline vitals recorded.
• Time Out performed: correct patient, side/site, procedure, consent, known risks.

Intra-procedure

• Operator uses ultrasound guidance when indicated; confirm vessel identification.
• Active sterile technique maintained; non-sterile staff remain clear of field.
• Needle/catheter insertion performed with guidewire and Seldinger technique as appropriate.
• Real-time confirmation of placement (ultrasound, waveform, blood return); document method.
• Chest x-ray or other imaging ordered and performed per local policy for central/venous thoracic placements.
• Hemostasis achieved on removal of introducer; secure catheter with approved device and dressing applied.
• Specimens labeled immediately at bedside if obtained, with two patient identifiers.

Post-procedure

• Document procedure details: site, catheter type, number of attempts, ultrasound use, complications, fluids/meds given, and personnel present.
• Confirm imaging results and document; if malposition suspected, take corrective action before use.
• Dressing and catheter care instructions provided; set next dressing change and line necessity review date.
• Ensure line labeling (e.g., lumen purpose) per local color/labeling policy.
• Monitor for immediate complications (bleeding, pneumothorax, arrhythmia, hypotension) for appropriate observation period.

Urinary Catheter Insertion (Foley) — Checklist

Pre-procedure

• Indication documented and alternatives considered (e.g., timed voiding, external devices).
• Consent (verbal/ written) and explanation given where appropriate.
• Allergies checked (latex/antiseptics).
• Equipment: correct catheter size/type, sterile kit, lubricant, drainage bag, securement device.
• Hand hygiene and sterile field prepared as per local policy.
• Time Out: confirm patient, procedure, allergies.

Intra-procedure

• Maintain aseptic technique; avoid unnecessary breaks in sterility.
• Advance catheter to appropriate depth before balloon inflation; confirm urine return when possible.
• Inflate balloon with recommended volume only after placement confirmed.
• Secure catheter and position tubing to avoid traction.

Post-procedure

• Document catheter type, size, insertion time, indications, and urine characteristics.
• Educate patient on catheter care and signs of infection; document teaching.
• Set a daily necessity review/stop date in the chart to avoid unnecessary prolonged catheterization.

Bedside Procedural Sedation — Checklist

Pre-procedure

• Clear indication and sedation plan documented; sedation provider and backup identified.
• Airway assessment completed and documented (Mallampati, mouth opening, neck mobility, BMI, difficult airway history).
• Fasting status verified per local policy; if not met, plan documented and risk discussed.
• Baseline vitals and relevant monitoring in place (continuous SpO2, ECG, noninvasive BP, capnography if available and per policy).
• Immediate availability of resuscitation and airway equipment, reversal agents, and trained personnel confirmed.
• Consent for sedation obtained and documented separately from procedural consent if required.
• Time Out performed including sedation level target and rescue plan.

Intra-procedure

• Continuous monitoring by a clinician dedicated to sedation and rescue (not the proceduralist when possible).
• Record medication doses and times, oxygen delivery, and capnography readings where used.
• Titrate sedation to planned level and reassess airway and hemodynamics frequently.
• Stop or reduce sedation at first sign of respiratory compromise or hemodynamic instability and enact rescue plan.

Post-procedure

• Document medications, total doses, complications, and patient status at handoff.
• Ensure recovery criteria met before transfer (airway protective reflexes, stable vitals, oxygenation) per local policy.
• Provide written discharge instructions if the patient leaves the unit, including escort requirements, activity restrictions, and when to seek care.

Basic Airway Management (Bag-mask, LMA, intubation preparation) — Checklist

Pre-procedure

• Assess airway and identify likely difficulty; ensure skilled backup is available if anticipated.
• Check and prepare airway equipment: bag-mask device, appropriate-sized masks, oropharyngeal/nasopharyngeal airways, suction, oxygen source, laryngoscopes (with blades), endotracheal tubes of multiple sizes, stylet, BVM, LMA, and capnography.
• Pre-oxygenation and monitoring in place; suction tested and ready.
• Assign roles for airway: primary intubator, assistant, medication provider, monitor/documenter.
• Time Out confirms plan, backup devices, and need for surgical airway equipment if indicated.

Intra-procedure

• Maintain situational awareness and clear communication during attempts; use check-speak for critical steps.
• Limit single attempt time and number per local policy; escalate to backup plan early when needed.
• Confirm placement with capnography waveform and chest rise; secure airway device immediately.

Post-procedure

• Document device, tube depth at teeth/lips, confirmation method, number of attempts, complications, and personnel.
• Establish plan for ventilation, sedation/analgesia, and ongoing monitoring.

Common failure modes and what to watch for

• Skipping Time Out or performing it when team attention is distracted.
• Inadequate documentation of consent, indications, or imaging confirmation.
• Breaks in sterile technique—consider a brief pause to re-establish sterility rather than continuing.
• Unclear role assignments leading to missed tasks (e.g., nobody documents or monitors sedation).
• Failure to set or enforce a catheter/line necessity review date, leading to avoidable device-days and infection risk.

Adaptation and local implementation notes

These checklists are intentionally generic. When adapting:

• Map each checklist item to your local policy or credentialing requirement and insert facility-specific wording (e.g., antiseptic type, required imaging, sedation fasting times).
• Decide what counts as completion (who initials, electronic checkbox, or documented phrase in the record).
• Assign an owner for periodic review (recommended every 12 months or after any adverse event related to the procedure).
• Consider converting these to Interactive checklists to capture completion, timestamps, complications, and to integrate daily device reviews.

Documentation template (suggested fields)

• Procedure, site, date/time, and staff present (by role).
• Indication and consent status.
• Equipment and monitoring used (ultrasound, capnography, chest x-ray required).
• Medications and doses administered.
• Number of attempts and any complications.
• Post-procedure instructions and follow-up imaging/results.

References and safety reminders

Do not use this pack as a substitute for local policies, clinical judgement, or facility credentialing requirements. Align these checklists with infection prevention guidelines, sedation policies, and airway management algorithms used at your organization.

Suggested next steps for teams: run a rapid tabletop using one checklist, then perform a PDSA cycle to test and refine local wording and role assignments. Collect feedback from frontline staff and update ownership annually.