COP 8: Documented procedures guide the care of patients undergoing
surgical procedures.
a) The surgeon does
assessment and provisional diagnosis is documented prior to the surgery. For
patients having specific health issues like diabetes, hypertension, renal
disease, etc. are advised to take fitness certificate from their treating
doctor who needs to be specialist.
b) Informed consent is
obtained by the surgeon prior to the procedure. _______Hospital maintains a list of
consent forms that are frequently used in the set up. The updated list is available
with the Hospital Administrator.
c) _______Hospital has
following SOP for prevention of adverse events like wrong side/eye, wrong
patient and wrong surgery besides other likely errors.
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SOP to prevent
Adverse Events during Surgery
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||
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Sr.
No.
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Process
Flow
|
Responsibly
|
|
1
|
It is verified from the patient
that he has stopped the medicines as per the advice of the doctor.
|
Treating Doctor
|
|
2
|
The
surgery site is marked with micropore tape, area was cleaned.
|
Nurse Asst./ OT
incharge
|
|
3
|
Pre-operative
check list is filled in.
|
|
|
4
|
OT
nurse while receiving the patient verifies from the patient his/her name and
type of surgery that is planned.
|
|
|
5
|
Doctor
asks the patient his/her name and the chief complaint or the type of surgery
that is going to be performed.
|
Doctor
|
|
6
|
Before
starting the surgery/ induction of anesthesia, TIME OUT done, the OT Nurse
loudly announces the name of the patient, the type of surgery, and Implant availability.
|
Nurse
Asst.
|
|
7
|
If any
discrepancy at any point of time arises, the surgery is withheld until the
discrepancy is resolved.
|
Treating
Doctor
|
d) _______Hospital ensures
that qualified persons are permitted to perform the procedures that they are
entitled to perform. The hospital maintains a list of Consultants along with
their qualifications certificates and Medical Council Registration No. The up to
date list is available with the Hospital Administrator.
e)
Post-operative notes are
prepared by the surgeon who includes procedure performed, post-operative
diagnosis, plan of care and status of the patient. Post-operative plan of care
includes
a.
Medications
b.
Care of the area
c.
Do’s & Don’ts during
initial period
d.
Infection control
practices to be observed at home
e.
Observations for any
complications
f)
The operation theater is
adequately equipped and monitored for infection control practices. The list of
equipment is available with the Hospital Administrator. Following Infection
Control practices are observed.
a.
The staff is trained on OT
cleaning, fumigation and other precautions to be observed.
b. The OT is normally closed
after fumigation and only opened during surgeries.
c.
All the instruments used
are autoclaved
d.
All articles used in OT
are sterilized.
e.
Sterilized drapes are used
for the patients.
f.
Staff wears sterile
clothes and OT footwear.
g.
All surgical staff is
vaccinated against Hepatitis B.
h.
Staff having wounds or
cuts should be excluded from the OT team
i.
Reusable instrument are
immersed in a tray.
j. Before entering OT all the
occupants change to OT clothes, does surgical hand wash and change to OT
footwear before entering.