Surgical Safety Protocol Template

Comprehensive Guidelines for Operating Room Safety and Risk Management

General Surgery

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Last updated: Mar 24, 2025

1. Pre-operative Safety Measures

Patient Verification

  • Verify patient identity using two identifiers
  • Confirm surgical site and procedure
  • Review consent forms and documentation
  • Check allergies and medication history

Surgical Site Marking

  • Mark surgical site with indelible marker
  • Perform time-out procedure
  • Document site marking in chart

2. Operating Room Safety

Equipment Check

  • Complete anesthesia machine check
  • Verify surgical equipment functionality
  • Confirm sterility indicators
  • Test emergency equipment availability

Personnel Safety

  • Proper PPE protocol adherence
  • Sharps safety procedures
  • Radiation safety measures when applicable
  • Fire safety protocol review

3. Intraoperative Safety

Universal Protocol

  • Pre-procedure verification
  • Site marking verification
  • Time-out procedure documentation

Specimen Management

  • Proper labeling protocol
  • Chain of custody documentation
  • Storage requirements compliance

4. Post-operative Safety

Patient Monitoring

  • Recovery room protocols
  • Vital signs documentation
  • Pain management guidelines
  • Post-op infection prevention

Documentation Requirements

  • Operative notes completion
  • Post-op orders documentation
  • Incident reporting protocol

5. Emergency Protocols

Emergency Response

  • Code team activation procedure
  • Emergency equipment location
  • Communication protocols
  • Evacuation procedures

6. Quality Assurance

Monitoring and Review

  • Regular safety audits
  • Incident review process
  • Staff competency assessment
  • Protocol update procedure

Review and update this protocol annually or as needed per facility requirements.

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