Surgical_safety_checklist_production Hirza.docx

Surgical Safety Checklist Before induction of anaesthesia (with at least nurse and anaesthetist) Has the patient confirmed his/her identity, site, procedure, and consent? Yes Is the site marked? Yes Not applicable Is the anaesthesia machine and medication check complete? Yes Is the pulse oximeter on the patient and functioning? Yes Does the patient have a: Known allergy? No Yes Difficult airway or aspiration risk? No Yes, and equipment/assistance available Risk of >500ml blood loss (7ml/kg in children)?

No Yes, and two IVs/central access and fluids planned

Before skin incision

Before patient leaves operating room

(with nurse, anaesthetist and surgeon)

(with nurse, anaesthetist and surgeon)

Confirm all team members have introduced themselves by name and role.

Confirm the patient’s name, procedure, and where the incision will be made.

Has antibiotic prophylaxis been given within the last 60 minutes? Yes Not applicable

Nurse Verbally Confirms: The name of the procedure Completion of instrument, sponge and needle counts Specimen labelling (read specimen labels aloud, including patient name) Whether there are any equipment problems to be addressed To Surgeon, Anaesthetist and Nurse:

Anticipated Critical Events

What are the key concerns for recovery and management of this patient?

To Surgeon: What are the critical or non-routine steps? How long will the case take? What is the anticipated blood loss? To Anaesthetist: Are there any patient-specific concerns? To Nursing Team: Has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns?

Is essential imaging displayed? Yes Not applicable

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. 2009

© WHO, 2009

Revised 1 /

Patient Safety

Surgical Safety Checklist – Sign In, Time Out dan Sign Out

Halaman 2/2

Dilakukan sebelum induksi anestesi, dihadiri minimal oleh perawat & ahli

Dilakukan sebelum insisi, dihadiri minimal oleh perawat, ahli anestesi,

Dilakukan sebelum pasien meninggalkan kamar operasi, dihadiri oleh perawat, ahli anestesi,

anestesi

operator

operator

Indikator

1.

Sudah Belum

Indikator

1.

Pasien telah dikonfirmasi meliputi :

Sebutkan nama dan peran masing-masing seluruh anggota tim

2.

1) Identitas dan gelang pasien

2.

Konfirmasi meliputi :

Ya

Tidak

Indikator

1.

Konfirmasi secara verbal tentang nama prosedur / tindakan :

2.

Jumlah instrument, sponge, jarum sesuai ?

2) Lokasi operasi

1) Nama pasien

3) Prosedur

2) Prosedur

Instrument

4) Persetujuan operasi

3) Lokasi insisi

Sponge

Profilaksis Antibiotik

Jarum

3.

Lokasi operasi sudah diberi tanda

3.

Mesin dan obat-obat anestesi sudah di cek lengkap

4.

Pulse oximeter sudah terpasang dan berfungsi

4.

Ya

Tidak

1)

Sudahkah diberikan 60 menit sebelumnya?

2)

Diberikan oleh............................

Pencegahan Kejadian Tidak Diharapkan (KTD)

Ya

Item

Pra

Intra

+

Pasca

Jumlah total

3.

Spesimen telah diberi label (minimal nama, alamat, no RM dan asal jaringan spesimen)

Bidang Bedah

4.

Adakah masalah dengan peralatan selama operasi

1) Apakah kemungkinan timbul kesulitan dalam

5.

Oleh Ahli Bedah, Ahli Anesthesi dan Perawat :

operasi ?

Tidak

Pesan khusus dari dokter bedah, dokter anestesi dan perawatan untuk perawatan di RR :

Apakah tindakan antisipasi telah disiapkan?

5.

Apakah pasien mempunyai riwayat alergi

6.

Kesulitan bernafas / risiko aspirasi? Tersediakah

2) Berapa estimasi lama operasi = ..............jam

.............................................................................................................................................................................. ..........................................................................................

3) Perkiraan kehilangan darah ............ cc

peralatan / bantuan

7.

Risiko kehilangan darah > 500 ml

(7 ml / Kg BB pada

Bidang Anestesi

Tanda Tangan

anak)

8.

Dua akses intravena / akses sentral dan rencana terapi

Adakah masalah khusus pada pasien ini dan

cairan

langkah antisipasi?

Dokter Operator

Dokter Anestesi

Perawat Sirkuler

Perawat Kamar Operasi

Bidang Keperawatan 1) Sudahkan cek alat steril 2) Adakah alat khusus

5.

Sudahkah hasil MRI, CT-Scan, Foto Rontgen terpasang ?