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Inpatient Pre-Operative Audit Tool

Inpatient Pre-Operative Audit Tool. Identifying and Resolving Issues with the Inpatient Pre-Operative Process. By: Mary Muse, RN, BSN Chair of Pre and Post-Operative Practice Committee. Role of the Pre-Op Nurse. Verify pt Name/DOB/MRN on ID band Prepare OR Paperwork:

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Inpatient Pre-Operative Audit Tool

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  1. Inpatient Pre-Operative Audit Tool Identifying and Resolving Issues with the Inpatient Pre-Operative Process By: Mary Muse, RN, BSN Chair of Pre and Post-Operative Practice Committee

  2. Role of the Pre-Op Nurse • Verify pt Name/DOB/MRN on ID band • Prepare OR Paperwork: • SBAR & Blood Status Forms • Label OR Flowsheet, charge form, etc. • Check MD order;Hang Pre-Op Antibiotics • Verify Allergies/Check for Red Allergy Band • Check IV Site/Access • Insert new PIV if existing is not working or less than 18 guage • Hang fluid (LR or .9NS) with blood tubing • Verify consents are signed: • Hospital,Surgical, and Anesthesia

  3. Role of the Pre-Op Nurse cont.. • Check Blood Status/Availability • Call Blood Bank/Check MD Order • Ensure operative site has been marked/initialled by surgical team • ***FINALIZE Pre-Op Checklist*** • Make sure patient is informed: • Have surgery AND anesthesia come to see patient & family? Answered questions?

  4. Identify the Problem… • Patients coming to the Pre-Op area NOT properly prepared for surgery…. • No Allergy Band, No Hospital consent • No Pre-Op Checklist Initiated,No IV Access • PCA pump connected to patient • Pts with belongings(dentures, contact lenses, Jewelry,Cell phones, etc) • Expired Blood Loc Codes/Type&Screen Order and Pre-Op Labs not drawn

  5. Purpose of Pre-Op Audit Tool • Gather Information: • Which errors are the most common? • Which floors have the highest or lowest incidence of error? • Determine the need for re-education on the floors/ICUs • Provide information to help improve the inpatient pre-op process • Allow Pre-Op RNs a way to improve professional practice

  6. Pre-Op Audit Tool Data

  7. Pre-Op Audit Tool Data

  8. What often happens as a result of these pre-op errors? • Pt surgery is cancelled! • Pre-Op RN is rushed to get pt ready • Pt safety may be compromised • Leaves room for error • OR cases are delayed • Surgeon/Anesthesia dissatisfaction • Pt dissatisfaction/frustration increases

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