Difficult Airway Cart Daily Check + Post-Use Restock Log
| DIFFICULT AIRWAY CART — DAILY CHECK & POST-USE RESTOCK LOG | |
| Hospital: ________________________ | Dept Anesthesia | Form Code: F-21 | Version: ___ | Effective: ___ | PAGE 1 of 1 |
| SECTION 1 — CART IDENTIFICATION | |
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Location/Area: ___________________________________ Cart ID/Number: _________________________________ |
Date: ________________
Shift: ☐ AM ☐ PM ☐ Night Checker name: ________________________________ Signature: _____________________________________ |
| SECTION 2 — DAILY READINESS CHECK |
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☐ Cart present in designated location and accessible
☐ Seal intact (if used) Seal #: ________________ ☐ N/A ☐ Cognitive aid/airway algorithm present (laminated) ☐ Video laryngoscope powers on + screen OK + battery OK ☐ Direct laryngoscope handle + blades available ☐ Bougie(s) available ☐ Stylets / tube exchangers available (as stocked)
☐ Supraglottic airway devices (SGA) sizes present:
☐ 3 ☐ 4 ☐ 5 (or local set) + pediatric sizes if applicable ☐ ETT sizes present (range) + syringes/ties ☐ Airway adjuncts: OPA/NPA available ☐ Suction catheters / yankauer available ☐ eFONA kit complete (cric kit / scalpel-bougie-tube) + in date ☐ Expiry check completed (critical single-use items)
Result:
☐ READY
☐ NOT READY (If NOT READY → remove from service until corrected)
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| SECTION 3 — DEFECT / RESTOCK ACTIONS (If Not Ready) |
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Missing/expired/nonfunctional items: _________________________________________________________________________________________________________ Action: ☐ Restocked now ☐ Biomedical notified ☐ Supply chain notified Reported to (Name): _____________________________________ Time: ________________ |
| SECTION 4 — POST-USE RESTOCK (Mini-Log) | ||||||||||||||||||||||||||||||||||||
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| SECTION 5 — FINAL SIGN-OFF |
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Returned to service / Cleared for use:
☐ Yes ☐ No
Name / Signature / Time: _________________________________________________
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