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Surgical Safety Checklist Guide

The document is a medical record for a patient named Michelle Cruz undergoing a dilatation and curettage procedure. It includes sections for signing the patient in and out of the procedure, reviewing safety checks, and having the surgeon, anesthesiologist and nurse sign confirming the procedure. Key information collected includes the patient's name, age, date of birth, procedure, and consents. Safety steps addressed include marking the surgical site, equipment function, antibiotics administration and reviews of anticipated critical events and concerns.

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nictan 14
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155 views1 page

Surgical Safety Checklist Guide

The document is a medical record for a patient named Michelle Cruz undergoing a dilatation and curettage procedure. It includes sections for signing the patient in and out of the procedure, reviewing safety checks, and having the surgeon, anesthesiologist and nurse sign confirming the procedure. Key information collected includes the patient's name, age, date of birth, procedure, and consents. Safety steps addressed include marking the surgical site, equipment function, antibiotics administration and reviews of anticipated critical events and concerns.

Uploaded by

nictan 14
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FEU- DR.

NICANOR REYES MEDICAL FOUNDATION


MEDICAL REYES
Regalado Avenue, West Fairview,Quezon City 1116, *Telephone Number : 427-213

Name :Michelle Cruz_______ Age:___21 yrs old____ Sex:  M F Date of Birth:__Nov 21 , 1999___ Hospital No.__________In patientOut patient
Scheduled Procedure:__Dilatation and Curettage ____________________

SIGN IN TIME IN SIGN OUT


Patient has confirmed Confirm all members have introduced themselves Nurse verbally confirms with the team
 Name by name or role
 Birthdate  Surgeon, anesthesiology and nurse verbally  Procedure done
Procedure confirm
Site  Patient  That instrument, sponge and needle
 surgical procedure/s Consent
 Site Counts are correct (Or not applicable)
 Consent for Anesthesia
site/side marked  procedure
Site marking available Anticipated Critical Events Specimen properly labeled(including
Surgeon reviews patients name)
Anesthesia safety check complete
Pulse oximeter on patient and fucntioning  What are the critical or unexpected
Does Patient Have a: steps, operative duration, anticipated  whether there are any equipment
Known Allergy? blood loss problems to be addressed
No  Anesthesia team reviews
Yes  Are there any patient-specific concerns Surgeon, anesthesiologist and Nurse
Difficult Airway/Aspiration risk  Nursing team reviews review the key concerns for recovery and
No  Has sterility ( including indicator results) management of this patient
Yes, Meds, equipment, assistance avaialble Been confirmed?
Risk of > 500ml Blood Loss  Are there equipment issues or any
7ml/kg in Children OPD/Ambulatory Home Instructions
concerns? Form accomplished
 No Has antibiotic prophylaxis been given
Yes, And Adequate intravenous access Within the last 60 minutes?
And fluid planned.
Yes
Not Applicable
Is essential Imaging displayed?
 Yes
Sign In Date: 8/17/2020_____ Time:_11:20pm_________  Not Applicable
Surgeon:_] Raul Duenas___MD_______________________
Name signature Time In: Date:_____8/17/2020______ Time:__11:48pm___ Sign out Date:_8/17/2020____ Time:_12:35 pm____
Anesth: :_. Raul Duenas___MD_______________________ Surgeon:___ Raul Duenas___MD_____ Surgeon_ Raul Duenas___MD_______
Name signature Name signature Name signature
Nurse:_ Alexandra Nicole Murillo RN___ ____ Anesth:__Raul Duenas MD____________ ___ Anesth:___Raul Duenas MD ________
Name signature Name signature Name signature
Nurse:___Alexandra Nicole Murillo RN________ Nurse:__Alexandra Nicole Murillo RN__________

SURGICAL SAFETY CHECKLIST

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