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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

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
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
role of the pre op nurse cont
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?
identify the problem
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
purpose of pre op audit tool
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
what often happens as a result of these pre op errors
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