Surgical site marking serves as an important basis for identifying the surgical patient so that the surgeon can be confident that the procedure is being performed on the correct patient and at the correct site.
I. What to do if incorrect identification is found
1. Inform the surgical team immediately: Immediately inform the surgeon, nurse manager and relevant surgical staff to ensure that they are aware of the mislabeling.
Stop the preparation for surgery: Suspend all preparations for surgery, including instrument placement and drug preparation.
3. Terminate the surgical procedure:If the surgery has not yet begun, immediately terminate the surgery and conduct a detailed verification of the patient's identity and the surgical program.
4. Stabilize the patient's condition: If the surgery has already begun, first stabilize the patient's condition to ensure his/her life safety.
5. Do not remove gowns and dressings: Retain current gowns and dressings to avoid further increasing the risk of infection.
6. Recheck patient identity: Use multiple methods (e.g., name, birth date, hospitalization
Recheck patient identity using multiple methods (e.g., name, date of birth, hospital number) to ensure that the patient is associated with the correct surgical procedure.
7. Reconcile the surgical program: Check the surgical request form, surgical consent form and surgical plan form to confirm that the surgical program is consistent with the patient's identity.
8、Notify superiors and related departments.
Supervising physician:Report the error to the supervising physician in a timely manner and seek his/her guidance and medical quality control department:Immediately notify the medical quality control department so that they can than intervene and assist in the handling of this misidentification incident.
9. Patient safety assessment and follow-up measures:Patient safety assessment:Conduct further safety assessment of the patient, including physical examination, laboratory tests, etc., to ensure that no other problems related to the surgical mislabeling have occurredFollow-up on the treatment plan:Determine the correct treatment plan based on the rechecked patient identity and surgical items, and initiate the appropriate treatment measures.
Second, how to prevent mislabeling
1、Nurses should pay attention to the protection of marking when doing preoperative preparation for patients, and should ask the doctor to re-mark if the marking is lost.
2、Operating room nurses pick up the patient, and ward nurses to check the medical records, check the patient's wristband identification and identification of the surgical site after checking the two sides in the "preoperative confirmation of surgical patients and the handover record" single signature; 3、Before the anesthesia begins, the nurse should pay attention to the protection of the logo, if the logo is lost, the doctor should be asked to re-identify.
3、Before the anesthesia starts, the anesthesiologist, the surgeon, and the visiting nurse check the medical record, the patient's wristband identification and the identification of the surgical site together, and confirm with the patient himself/herself, and after confirming that there is no error, the three parties sign on the "Surgical Patient Pre-operative Confirmation and Handover Record" sheet.