165438+ 12. Check the information and expiration date on the labels of prosthetic materials and instruments implanted during the operation, and the bar code should be attached to the back of the surgical nursing record. 13. When autologous blood transfusion is performed during operation, the clinical blood transfusion technical specifications should be strictly implemented, and the anesthesiology department should be informed to prepare font blood recovery equipment. 14. Before and after the operation, a doctor's order must be issued by the surgeon or a doctor authorized by the operator. 15. Special treatment, antibacterial drugs and narcotic and analgesic drugs shall be implemented in accordance with relevant state regulations. 16. It is necessary to do a good job in the management and preparation of perioperative patients. If anesthesia consultation is needed before operation, clinical departments and anesthesiology departments should do a good job in preoperative evaluation of patients. Anesthesiology department and operating room should strengthen monitoring, make records and report in time. If there is any violation of the above provisions, report to the medical department for handling. System and process of surgical safety verification. Surgical safety verification refers to the work that surgeons, anesthesiologists and surgical nurses jointly participate in the verification of patients' identity and surgical site before anesthesia, surgery and patients leave the operating room. The verification results are confirmed and signed by anesthesiologists, surgeons and operating room nurses. The surgeon referred to in this system refers to the operator or the first assistant. Two, surgical patients should wear signs indicating the patient's identity information for verification. Third, the content and process of implementing surgical safety verification. (1) Before anesthesia: the surgeon presides over the operation, and the anesthesiologist and the operating room nurse check the patient's identity (name, sex, age, medical record number), operation mode, informed consent, operation site and label, anesthesia safety inspection, skin integrity, surgical field skin preparation, venous access establishment, patient allergy history, skin test results of antibacterial drugs and infectious diseases in turn according to the contents in the operation safety checklist. (2) Before the operation, anesthesiologists, surgeons and operating room nurses should check the patient's identity (name, sex, age), operation mode, operation site and label, and confirm the risk warning in the above way. The operating room nurse verifies the preparation of surgical items and reports to the surgeon and anesthesiologist.
(3) Before the patient leaves the operating room, the nurses, surgeons and anesthesiologists in the operating room should check the patient's identity (name, sex and age) and the actual operation mode, count the operation materials, confirm the surgical specimens, check the skin integrity, arteriovenous access and drainage tube, and confirm the patient's whereabouts. (4) The inspectors of the three parties shall sign separately after confirmation. (five) the verification process requires the host to sing and read. Fourthly, the operation safety checklist is proposed by the dispatching room and presided over by the inspection. Five, after the operation, the visiting nurse is responsible for timely counting and checking the blood, instruments, dressings and other items used in the operation, and the visiting nurse and the surgical instrument nurse sign and fill in the operation counting record. Operation inventory records in duplicate, one in the operating room and one in the medical record. Operation inventory records include patient's name, inpatient medical record number (or medical record number), operation date, operation name, inventory and signature of various instruments and dressings used in the operation, etc. Six, this system is suitable for all kinds of surgery at all levels, other invasive surgery should refer to the implementation. Seven, surgical safety verification must be carried out in accordance with the above steps in turn, and the next step can be carried out only after each step is verified. It is not allowed to fill in the form in advance. Eight, intraoperative medication verification: by the surgeon or anesthesiologist according to the situation need to issue orders and make corresponding records, by the operating room nurse is responsible for the verification. Nine, the head of the operating department, anesthesiology department and operating room is the main person responsible for the implementation of the operation safety verification system and continuous improvement management. Ten, the hospital medical department, nursing department and other medical quality management departments should, according to their respective responsibilities, conscientiously perform the supervision and management of the implementation of the surgical safety verification system, put forward continuous improvement measures and implement them. Eleven, surgical safety verification, jointly supervised by the surgeon, anesthesiologist and operating room nurse, for failing to implement surgical safety verification in accordance with the above provisions, the surgeon, anesthesiologist and operating room nurse shall be detained respectively according to 50 yuan/case. And was informed in the hospital. 12. The operation safety checklist should be kept in the medical record. If there is no surgical safety checklist, it will be regarded as unqualified medical records (rejected by single vote), and the competent physician will handle it according to the relevant regulations of unqualified medical records. Thirteen, ward and operating room should establish a handover system between the operating room, in strict accordance with the requirements of the ward round system for handover item by item. Surgical Risk Assessment System and Process In order to ensure medical quality, ensure patients' life safety and make patients' surgical effects scientifically and objectively evaluated, doctors in charge of diagnosis and treatment should make detailed and scientific surgical plans suitable for each patient according to patients' conditions and individual differences, and adjust and modify the surgical plans in time when patients' conditions change, so that patients can get timely, scientific and effective treatment. Our hospital has established a surgical risk assessment system for patients. 1. All surgical patients should undergo surgical risk assessment.
2. Doctors and anesthesiologists should comprehensively evaluate the risks, advantages and disadvantages of the proposed operation in strict accordance with the medical history, physical examination, imaging and laboratory data, and clinical diagnosis. 3. Before the operation, the competent physician, anesthesiologist and visiting nurse should evaluate the patients one by one according to the contents of the operation risk assessment form, and make a safe, reasonable and effective operation plan and anesthesia method according to the evaluation results and preoperative discussion. Necessary preoperative information must be made to inform the patient or his client of the operation plan and the possible risks of the operation, and the patient or his client should sign it. When the surgical risk assessment level exceeds the NNIS2 level, it should ask the department director for instructions in time and ask the department director to re-evaluate. If necessary, post-consultation evaluation can be organized. 4. If the patient cannot be treated in our hospital after admission or the treatment effect is uncertain, he should communicate with his family members in time, negotiate treatment in our hospital or transfer to another hospital, and make necessary informed notification. 5. Fill in the content and process of surgical risk assessment 24 hours before operation. Surgeons, anesthesiologists and visiting nurses evaluate patients according to the corresponding content of the surgical risk assessment form, and sign the signature column after making the assessment. The surgeon calculates the surgical risk level according to the evaluation content. The evaluation contents are as follows: ① Cleanliness of surgical incision: Classification standard of surgical risk According to cleanliness, surgical incision is divided into four categories: type I surgical incision (clean operation), type II surgical incision (relatively clean operation), type III surgical incision (clean-contaminated operation) and type IV surgical incision (contaminated operation). ② Anesthesia grading (ASA grading) refers to the condition grading standard of American Association of Anesthesiologists (ASA): I-VI grade: P65438+. P2: The patient's clinical symptoms are mild; P3: The patient has obvious systemic clinical symptoms; P4: The patient has mild and obvious systemic clinical symptoms and is life-threatening; P5: terminally ill patients whose lives are difficult to sustain; P6: Brain-dead patients. ③ Operation Duration Operation Risk Grading Standard According to the operation duration, patients were divided into two groups: "The operation was completed within 3 hours"; "Surgery completed in more than 3 hours" belongs to emergency surgery. Put "√" in □ ". ④ The type of operation shall be marked "√" by the anesthesiologist in the corresponding "□". ⑤ Follow-up: The patient's wound healing and infection should be filled in by the competent doctor within 24 hours after discharge. Surgical site identification system and process 1. Before elective surgery or emergency surgery, the responsible nurse should check the patients (including bed number, name, sex, age, name of surgery and surgical site) according to the doctor's advice.
Second, after checking and confirming, prepare the skin in the operation area. Third, put a wristband on the patient's wrist, indicating the bed number, name, operation name and left and right surgical sites. Four, patients to the operating room, the responsibility of the nurse to check the patient's bed number, name, name and location of the operation, and check the skin preparation again. V. Procedure for confirming surgical patients: 1. The operator should dip gentian violet in the body surface of the patient's surgical site with a marker pen or cotton swab one day before operation or after prescribing the operation, and take "+"as the marking sign, and confirm and check the surgical site with the patient or his family. 2. When picking up the patient, the operating room staff and the ward nurse * * * will check the patient's bed number, name, gender, age, disease diagnosis, operation name and body surface identification of the operation site, and sign it after confirmation, and send the patient to the operating room. 3, surgeons, anesthesiologists, operating room nurses, patients, before the start of anesthesia, should check in four directions, especially when it comes to the left and right sides, reconfirm the body surface identification of the surgical site and sign it. 4. The operator, anesthesiologist and operating room nurse should check the patient's name, gender, age, surgical site and body surface identification (especially the left and right sides) again before the operation, and the operation can be started only after it is confirmed. Effectively achieve the "three confirmations" before the implementation of surgical anesthesia, before the start of surgery, and before the patient leaves the operating room. 5, involving bilateral, multi-structure (fingers, toes, lesions), multi-plane parts (spine) surgery, surgical side or part has a standardized and unified mark, the implementation rate of surgical marking is ≥95%. Six, for surgical patients without surgical site and body surface identification, anesthesiology can refuse to take patients into the operating room. This regulation shall be implemented from 20 15 1+0. Medical department 20 14 12 10 preoperative visit system for anesthesiologists 1. Anesthesiologists should visit patients the day before elective surgery. Inform patients or clients about anesthesia methods, possible accidents, complications, risks related to postoperative analgesia and other issues. After obtaining the consent of the patient, the agent and the authorized person, both doctors and patients should sign the informed consent form of anesthesia (notification form). Second, the special patients who receive the anesthesia consultation form should consult in time and record it in the course of the disease according to the writing format.
Three, preoperative rounds record format according to the "Guizhou province medical record writing standard" (Trial). The main records include: current diagnosis, brief medical history and diagnostic basis, current situation (preoperative precautions and abnormal auxiliary examination results), anesthesia contraindications and indications. 4. Preoperative visit includes: (1) comprehensive understanding of the patient's health status; (2) Cardiopulmonary function; (3) X-ray examination (MRI, CT) and various laboratory examination results; (4) Preoperative preparation for special patients; (5) Whether it is sufficient; (six) the surgical site and anesthesia method; (seven) to carry out the necessary physical examination. Perform special examination according to anesthesia method. Such as spinal block anesthesia to check the spine; (eight) general anesthesia pay attention to the presence of false teeth, tracheal intubation incisors are complete, neck length and mobility. Other tumors with difficulty in arteriovenous puncture have an impact on respiratory circulation. Five, understand the patient's mental state and the requirements of anesthesia, for the implementation of local anesthesia (spinal anesthesia and regional block) must be patiently explained to eliminate the patient's fear. Six, according to the patient's medical history and examination results, decide the anesthesia method. Seven, preoperative preparation of anesthesia equipment, anesthesia drugs and anesthesia machine. Eight, the preparation before anesthesia is not perfect, due to check has not been carried out or need to review, and anesthesia is difficult or dangerous, should be put forward to the ward doctor during the preoperative visit, * * * cooperate with consultation, report to the superior doctor or medical authorities when necessary, in order to properly handle.
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Relevant system of preoperative preparation for surgical patients
Preoperative preparation system for surgical patients
1. Doctors at all levels should strictly grasp the surgical indications for patients who need surgical treatment, and complete all preoperative preparations and necessary examinations in time. Patients preparing for blood transfusion must check their blood type and infection screening (liver function, hepatitis B virus, hepatitis C virus, HIV, syphilis antibody).
2. Patients undergoing elective surgery must improve the relevant preoperative preparation and complete the relevant preoperative examination. If any abnormality is found in the inspection, it should be reported to the superior doctor in time or the relevant department should be consulted, and the consultation opinions should be implemented, so as to strictly control the surgical indications.
3. Before the operation, the surgeon and anesthesiologist must examine the patient in person, and perform the obligation of informing the patient and his family or the patient's authorized agent, including the patient's condition, operation mode, operation risk, anesthesia risk, and self-funded items. , with the consent and signature of the patient or the patient's authorized agent. In case of emergency surgery or emergency patients can't sign, patients or authorized agents can't sign in time when they are not in the hospital, according to the relevant provisions of the Regulations on the Administration of Medical Institutions, report to the superior, and make detailed records in the medical records.
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4. The competent physician should make preoperative summary records. Surgery above moderate level needs preoperative discussion. Preoperative discussion of major surgery, special patient surgery and new surgery should be presided over by the director of the department to discuss and formulate the surgical plan. The discussion should be recorded in the preoperative discussion book and the course record, and reported to the medical department or the business dean for approval.
5. The surgeon should be determined according to the operation classification management system. Major operations and various exploratory operations must be carried out by experienced doctors or department directors with the title of deputy chief physician or above, and the medical department must be reported if necessary.
6. The operation schedule should be notified to the operating room one day in advance to check the implementation of preoperative nursing work and the preparation of special instruments. All medical behaviors should be recorded in the medical records. If there is any disease that is not conducive to surgery, please consult the relevant departments in time.
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7. Before the operation, the patient should fix the wrist strap for identification, and the marked information is accurate; At the same time, the surgical site was marked.
8. Preoperative preparation should be based on the system, and it is forbidden for acquaintances to operate in advance without adequate preparation and evaluation before operation.
9. The operating room has the right to refuse patients who have not completed the relevant preoperative preparation to enter the operating room for surgery, and the clinical surgeon is responsible for explaining and communicating with the patients or their families.
10. Medical staff should carefully check the patient's name, gender, medical record number, bed number, diagnosis, operation site, operating room, etc. Patients need to take out their dentures before entering the operating room, and valuables should be kept by their families.
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165438+
12. Check the information and expiration date on the labels of prosthetic materials and instruments implanted during the operation, and the bar code should be posted on the back of the surgical care record.
13. When autologous blood transfusion is performed during operation, the clinical blood transfusion technical specifications should be strictly implemented, and the anesthesiology department should be informed to prepare font blood recovery equipment.
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14. Before and after the operation, a doctor's order must be issued by the surgeon or a doctor authorized by the operator.
15. Special treatment, antibacterial drugs and narcotic and analgesic drugs shall be implemented in accordance with relevant state regulations.
16. It is necessary to do a good job in the management and preparation of perioperative patients. If anesthesia consultation is needed before operation, clinical departments and anesthesiology departments should do a good job in preoperative evaluation of patients. Anesthesiology department and operating room should strengthen monitoring, make records and report in time. If there is any violation of the above provisions, report to the medical department for handling.
Operational safety verification system and process
A, surgical safety verification is by the surgeon, anesthesiologist, surgical nurse * * * to participate in, respectively, before anesthesia, before the start of the operation and the patient before leaving the operating room, at the same time, the patient's identity and surgical site for verification. The verification results are confirmed and signed by anesthesiologists, surgeons and operating room nurses. The surgeon referred to in this system refers to the operator or the first assistant.
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Two, surgical patients should wear signs indicating the patient's identity information for verification.
Third, the content and process of implementing surgical safety verification.
(1) Before anesthesia: the surgeon shall preside over the operation, and the anesthesiologist and the operating room nurse shall check the patient's identity (name, sex, age, medical record number), operation mode, informed consent form, operation site and label, anesthesia safety inspection, skin integrity, surgical field skin preparation, venous access establishment, patient allergy history, skin test results of antibacterial drugs and infectious diseases in turn according to the contents in the operation safety checklist.
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(2) Before the operation, anesthesiologists, surgeons and operating room nurses should check the patient's identity (name, sex, age), operation mode, operation site and label, and confirm the risk warning in the above way. The operating room nurse verifies the preparation of surgical items and reports to the surgeon and anesthesiologist.
(3) Before the patient leaves the operating room, the nurses, surgeons and anesthesiologists in the operating room should check the patient's identity (name, sex and age) and the actual operation mode, count the operation materials, confirm the surgical specimens, check the skin integrity, arteriovenous access and drainage tube, and confirm the patient's whereabouts. (4) The inspectors of the three parties shall sign separately after confirmation.
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(five) the verification process requires the host to sing and read.
Fourthly, the operation safety checklist is proposed by the dispatching room and presided over by the inspection. Five, after the operation, the visiting nurse is responsible for timely counting and checking the blood, instruments, dressings and other items used in the operation, and the visiting nurse and the surgical instrument nurse sign and fill in the operation counting record. Operation inventory records in duplicate, one in the operating room and one in the medical record. Operation inventory records include patient's name, inpatient medical record number (or medical record number), operation date, operation name, inventory and signature of various instruments and dressings used in the operation, etc. Six, this system is suitable for all kinds of surgery at all levels, other invasive surgery should refer to the implementation. Seven, surgical safety verification must be carried out in accordance with the above steps in turn, and the next step can be carried out only after each step is verified. It is not allowed to fill in the form in advance.
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Eight, intraoperative medication verification: by the surgeon or anesthesiologist according to the situation need to issue orders and make corresponding records, by the operating room nurse is responsible for the verification.
Nine, the head of the operating department, anesthesiology department and operating room is the main person responsible for the implementation of the operation safety verification system and continuous improvement management.
Ten, the hospital medical department, nursing department and other medical quality management departments should, according to their respective responsibilities, conscientiously perform the supervision and management of the implementation of the surgical safety verification system, put forward continuous improvement measures and implement them.
Eleven, surgical safety verification, jointly supervised by the surgeon, anesthesiologist and operating room nurse, for failing to implement surgical safety verification in accordance with the above provisions, the surgeon, anesthesiologist and operating room nurse shall be detained respectively according to 50 yuan/case. And was informed in the hospital.
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12. The operation safety checklist should be kept in the medical record. If there is no surgical safety checklist, it will be regarded as unqualified medical records (rejected by single vote), and the competent physician will handle it according to the relevant regulations of unqualified medical records.
Thirteen, ward and operating room should establish a handover system between the operating room, in strict accordance with the requirements of the ward round system for handover item by item.
Surgical risk assessment system and process
In order to ensure the quality of medical treatment, ensure the safety of patients' lives, and make the surgical effect of patients scientifically and objectively evaluated, the doctors in charge of diagnosis and treatment should formulate detailed and scientific surgical plans suitable for each patient according to the patient's condition and individual differences, and can adjust and modify the surgical plans in time when the patient's condition changes, so that patients can get timely, scientific and effective treatment. Our hospital has formulated a surgical risk assessment system for patients. 1. All surgical patients should undergo surgical risk assessment.
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2. Doctors and anesthesiologists should comprehensively evaluate the risks, advantages and disadvantages of the proposed operation in strict accordance with the medical history, physical examination, imaging and laboratory data, and clinical diagnosis.
3. Before the operation, the competent physician, anesthesiologist and visiting nurse should evaluate the patients one by one according to the contents of the operation risk assessment form, and make a safe, reasonable and effective operation plan and anesthesia method according to the evaluation results and preoperative discussion. Necessary preoperative information must be made to inform the patient or his client of the operation plan and the possible risks of the operation, and the patient or his client should sign it. When the surgical risk assessment level exceeds the NNIS2 level, it should ask the department director for instructions in time and ask the department director to re-evaluate. If necessary, post-consultation evaluation can be organized.
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4. If the patient cannot be treated in our hospital after admission or the treatment effect is uncertain, he should communicate with his family members in time, negotiate treatment in our hospital or transfer to another hospital, and make necessary informed notification.
5. The content and process of surgical risk assessment
24 hours before operation, surgeons, anesthesiologists and visiting nurses evaluate patients according to the corresponding contents of the surgical risk assessment form, and sign their names on the signature column after making the evaluation. The surgeon calculates the surgical risk level according to the evaluation content. The evaluation contents are as follows:
(1) surgical incision cleanliness surgical risk grading standard surgical incisions are divided into four categories according to cleanliness:
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Class I surgical incision (clean operation)
Type Ⅱ surgical incision (relatively clean incision)
Class Ⅲ surgical incision (clean and polluted operation)
Type Ⅳ surgical incision (contaminated operation)
② The classification of anesthesia (ASA classification) refers to the condition classification standard of American Association of Anesthesiologists (ASA): I-VI:
P 1: normal patients;
P2: The patient's clinical symptoms are mild;
P3: The patient has obvious systemic clinical symptoms;
P4: The patient has mild and obvious systemic clinical symptoms and is life-threatening;
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P5: terminally ill patients whose lives are difficult to sustain;
P6: Brain-dead patients.
③ Duration of operation
According to the duration of operation, the patients were divided into two groups according to the classification standard of operation risk: "Complete the operation within 3 hours"; "Surgery completed in more than 3 hours" belongs to emergency surgery. Put "√" in □ ".
④ The type of operation shall be marked "√" by the anesthesiologist in the corresponding "□".
⑤ Follow-up: The patient's wound healing and infection should be filled in by the competent doctor within 24 hours after discharge.
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Surgical site identification system and method
1. Before elective surgery or emergency surgery, the nurse in charge should check the patient according to the doctor's advice (including bed number, name, sex, age, operation name and operation site).
Second, after checking and confirming, prepare the skin in the operation area.
Third, put a wristband on the patient's wrist, indicating the bed number, name, operation name and left and right surgical sites.
Four, patients to the operating room, the responsibility of the nurse to check the patient's bed number, name, name and location of the operation, and check the skin preparation again.
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Five, surgical patient confirmation process:
1, the surgeon should mark the body surface of the patient's surgical site with a marker pen or a cotton swab dipped in gentian violet one day before operation or after the operation, with a "+"as the identification mark, and confirm and check the surgical site with the patient or his family.
2. When picking up the patient, the operating room staff and the ward nurse * * * will check the patient's bed number, name, gender, age, disease diagnosis, operation name and body surface identification of the operation site, and sign it after confirmation, and send the patient to the operating room.
3, surgeons, anesthesiologists, operating room nurses, patients, before the start of anesthesia, should check in four directions, especially when it comes to the left and right sides, reconfirm the body surface identification of the surgical site and sign it.
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4. The operator, anesthesiologist and operating room nurse should check the patient's name, gender, age, surgical site and body surface identification (especially the left and right sides) again before the operation, and the operation can be started only after it is confirmed. Effectively achieve the "three confirmations" before the implementation of surgical anesthesia, before the start of surgery, and before the patient leaves the operating room.
5, involving bilateral, multi-structure (fingers, toes, lesions), multi-plane parts (spine) surgery, surgical side or part has a standardized and unified mark, the implementation rate of surgical marking is ≥95%.
Six, for surgical patients without surgical site and body surface identification, anesthesiology can refuse to take patients into the operating room. This regulation shall be implemented from 20 15 1+0.
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Medical department
20 14 12 10
Anesthesiologists' preoperative visit system for safe operation.
First, the anesthesiologist should visit the patient one day before elective surgery, and inform the patient or client about anesthesia methods, possible accidents, complications, risks related to postoperative analgesia, etc. After obtaining the consent of the patient or the agent and the authorized person, the informed consent (notice) of anesthesia should be signed by both doctors and patients. Second, the special patients who receive the anesthesia consultation form should consult in time and record it in the course of the disease according to the writing format.
Three, preoperative rounds record format according to the "Guizhou province medical record writing standard" (Trial). The main records include: current diagnosis, brief medical history and diagnostic basis, current situation (preoperative precautions and abnormal auxiliary examination results), anesthesia contraindications and indications.
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Four, preoperative visit content includes:
(a) a comprehensive understanding of the health status of patients;
(2) Cardiopulmonary function;
(3) X-ray examination (MRI, CT) and various laboratory examination results;
(4) Preoperative preparation for special patients;
(5) Whether it is sufficient;
(six) the surgical site and anesthesia method;
(seven) to carry out the necessary physical examination. Perform special examination according to anesthesia method. Such as spinal block anesthesia to check the spine;
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(eight) general anesthesia pay attention to the presence of false teeth, tracheal intubation incisors are complete, neck length and mobility. Other tumors with difficulty in arteriovenous puncture have an impact on respiratory circulation.
Five, understand the patient's mental state and the requirements of anesthesia, for the implementation of local anesthesia (spinal anesthesia and regional block) must be patiently explained to eliminate the patient's fear.
Six, according to the patient's medical history and examination results, decide the anesthesia method.
Seven, preoperative preparation of anesthesia equipment, anesthesia drugs and anesthesia machine.
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Eight, the preparation before anesthesia is not perfect, due to check has not been carried out or need to review, and anesthesia is difficult or dangerous, should be put forward to the ward doctor during the preoperative visit, * * * cooperate with consultation, report to the superior doctor or medical authorities when necessary, in order to properly handle.