“Surgical Safety Audit” 51 operations ( 15/3/2010 – 19/3/2010 ) Surgery O&T O&G ENT Dental Pain Eye 23 12 6 2 4 EOT Elective 16 35 Compliance Observations Only 57% of cases have conducted “Briefing” (Anticipated critical events) Only 39% of cases have conducted “Debriefing”(Key concerns reviewed) A marking was found to have marked on a tegaderm but not the skin A “x” mark was found instead of a “↑” “Known alerts/allergy” was neglected in Briefing Only 46% of the Time-out were conducted by Chief Surgeon 36% of cases have “Consenting”, “123SS123” & “Time-out” conducted by the same surgeon. 100% 21 out of 25 questions 88% Q5 Document & sign as appropriate (Sign-in) 96% Q16 Check for known alerts 92% Q19 Document & sign as appropriate (Time-out) Q25 Document & sign as appropriate (Sign-out) Conclusions and Improvement We have made a big and satisfactory progress in compliance The checklist should be signed after performing the checking Unify the marking procedure Reinforce the Briefing & Debriefing Remind one and other about “known alerts/allergy”
“手術安全審計” 結 論 與 改 善 Compliance 依從率 Observations 觀察 51 項 手術( 15/3/2010 – 19/3/2010 ) 外科 骨科 婦產科 耳鼻喉科 牙科 痛症 眼科 23 12 6 2 4 急症手術 常規手術 16 35 Compliance 依從率 Observations 觀察 只有57%的病例有做“Briefing” (預期的重要事件) 只有39%的病例有做“Debriefing” (已檢討的關鍵問題 ) 發現一個記號標在 tegaderm上,而不在皮膚上 “x”標記被發現，而不是一個“ ↑ ” 於“Briefing”中，忽視了已知的警告/過敏” 只有46％的“手術前核查措施”是由主刀外科醫生進行 36％的手術上, 同一個外科醫生進行“Consenting process”， “123SS123”和“手術前核查措施”。 100% 21 out of 25 questions 88% Q5 簽署 (Sign-in) 96% Q16 提醒已知的警示 92% Q19 簽署(Time-out) Q25 簽署(Sign-out) 結 論 與 改 善 我們已經取得了很大和令人滿意的進展 查閱後應簽署清單 統一及強化記號程序 提醒及強化 Briefing及Debriefing 提醒其他人有關於“已知的警示/過敏”