VERSION 1

SAFE SURGERY CHECKLIST CODE: DNCSS.MSP.01

DATE: 04-21-2016

Health facility: ________________________________ Unicode: ________________ Date: _______________

Name of patient: ________________________________ Age: _____________________________________
Medical history number: ________________________________ Operating room number:
_____________________________________
Procedure: ____________________________________________________________________________________________

ENTRANCE EXIT
SURGICAL PAUSE
(Before induction of anesthesia) (Before the patient leaves the operating room)
(Before skin incision)
The patient has confirmed: The person responsible for the checklist verbally
Confirmation that all team members have
BUT confirms with the surgical team:
introduced themselves by name and role
surgical site
FINAL count of surgical blanks and instruments (prior
BUT
to closure) is complete
The procedure
Person responsible for the checklist verbally
BUT
Your verbal consent confirms with the surgical team:
and written BUT
There was a need to package the patient
Surgical site demarcation Patient identity
IF NO NOT APPLICABLE surgical site
BUT
Procedure (laterality)
Record the number of pads______________ __
Formal control of anesthetic instruments,
Forecasting critical events
medication and anesthetic risk has been Name of the procedure performed
The surgeon expresses:
completed. BUT ___________________________________________
BUT
intubation equipment ___________________________________________
Duration of the procedure
Expected blood loss
Airway aspiration equipment Wound classification
Clean Contaminated
Ventilation system The anesthesiologist expresses a specific
Clean contaminated Dirty
Oxygen problem
Inhaled drugs Sampling
Medication BUT
BUT
Nursing and/or surgical instrumentation team
Pulse oximeter placed on the patient and working checks:
Labeling of samples (full names and surnames of the
BUT
BUT patient, medical history, date)
Sterility (resulting in
indicators and integrators
Capnograph in place and working BUT
internal and external chemicals
IF NO NOT APPLICABLE
Identify the type of sample to send
INITIAL material count
Does the patient have known allergies? white and surgical instruments
Chemical Cyto No._____________
IF NO which ones:_________________
Name: ________________________________
Questions or related problems
Crops No. _____________
Difficult airway/risk of aspiration With instruments and equipment
Name: __________________________________
Yes, and there are instruments and Anatomopathological No. ___________
equipment available Antibiotic prophylaxis has been administered
Name: __________________________________
NO in the last 60 minutes
Others:____________________________________
_
IF NO NOT APPLICABLE
Risk of bleeding > 500 ml (7 ml/kg in children) __________________________________________
Yes, and provision has been made for the __________________________________________
Essential diagnostic images are available for
availability of intravenous access and If there are problems to resolve, related to
the surgical procedure.
adequate fluids. instruments and equipment
BUT
NO IF NO NOT APPLICABLE
Which is
it:_____________________________________
The reserve of blood products has been confirmed ___________________________________________
with the laboratory. ___________________________________________
IF NO NOT APPLICABLE The surgeon, anesthesiologist and nursing staff
review the main aspects of the patient's recovery
BUT
Signature and stamp Signature and stamp Signature and stamp

Full name of the person responsible for

the checklist Surgeon's full name Anesthesiologist's full name
 VERSION 1
SAFE SURGERY CHECKLIST CODE: DNCSS.MSP.01
DATE: 04-21-2016

PROFILAXIS ANTIBIOTICA
Administar profilaxis
antibiotica 60 minutos
antes del procedimiento
quirúrgico, ajustada en
base al peso del paciente
y de acuerdo al protocolo
institucional.
REMOCION DEL BELLO
ANTISEPSIA DE LA No remover el vello del area
PIEL de incision quirurgica, a no ser
que este interfiera con el
Utilizar agentes para procedimiento quirurgico. En
la antisepsia de la piel caso de ser necesario:
que contengan NO lo realice en el interior del
alcohol si no hay quirofano.
contraindicaciones
NO utilice afeitadoras SI NO
como, el gluconato de máquinas de cortar eléctricas o
clorhexidina o un un agente depilatorio, de ser
yodoforo el caso.Evite el paciente se
rasure en el domicilio

Sabia usted que

para prevenir
infecciones de
sitio quirúgico
DEBEMOS!

TEMPERATURA
GLICEMIA
Registrar los valores
Registar la glicemia
de temperatura del
del paciente a una
paciente cada 15 a
hora fija el 1ro, 2do y
3er día posoperatorio 30 minutos durante
y mantener la la cirugia. Mantener
glicemia menos de la temperatura
200 mg/dl. central mayor a 36° c
OXIGENACION durante la cirugía
Optimizar la oxigenacion
del tejido mediante la
administración
suplementaria de
oxígeno durante e
inmediatamente
despeues de los
procedimientos
quirúrgicos que implican
anestesia general