手术和侵入性检查治疗安全核查制度.docVIP

文件名称

Document

文件类别：制度

Documentcategory：Policy

文件编号：

YL-AZ-0006-001

Documentnumber:

YL-AZ-0006-001

手术和侵入性检查/治疗安全核查制度

Surgeryorinvasiveexamination/treatment

safetyverificationpolicy

责任部门：医疗部

Responsibledepartment：DepartmentofMedicalServices

首发日期：2014-10-28

Dateestablished：2014-10-28

附件：0个共0页

Appendix：0(0page)

新订日期：2014-10-28

Daterevised：2014-10-28

版本：第1版，5页

Version：Ver.1(5pages)

1.标准Standard

医院制定及实施即将手术和侵入性检查/治疗前的暂停确认以确保正确的位置，正确的处置及正确的病人。Implementhospitalestablishedtime-outpriortosurgery/invasiveprocedures(examinationortreatment)toverifycorrectprocedure-site,procedure,andpatient.

2.目的Purpose

手术和侵入性检查/治疗即将开始前的暂停确认需全体医疗团队成员一起共同参与，并澄清所有未清楚事项。必需在手术即将开始前在手术执行地点执行。病人不需参与，医院需收集此过程。Thetime-out,heldimmediatelybeforethestartofthesurgeryorinvasiveexamination/treatmentwithallteammemberspresent,permitsanyunansweredquestionsorconfusiontoberesolved.Thetime-outisconductedinthelocationatwhichtheprocedurewillbedone,justbeforestartingtheprocedure,andinvolvestheentireoperativeteam.Thepatientdoesnothavetoparticipateinthetime-outprocedure.Thehospitalisrequiredtodocumentthistime-outprocess.

手术和侵入性检查/治疗前的确认流程目的在确认正确位置，处置及病人，确保相关文件影像及检查完备，备妥之特别技术或植入物。Thepurposeofthepreoperativeverificationprocessistoverifythecorrectprocedure-site,procedure,andpatient;toensurethatallrelevantdocuments,images,andstudiesareavailable,properlylabeled,anddisplayed;andverifythatanyrequiredspecialmedicaltechnologyand/orimplantsarepresent.

3.范围Scope

3.1适用范围：所有门诊、急诊及住院病人所有即将手术或侵入性处置前均需暂停确认。Applicationscope:Alloutpatient,emergency,andinpatientsurgeryorinvasiveproceduresrequireatime-outprocess.

3.2流程范围：始于病人即将开刀或侵入性检查/治疗前,终于病人开刀或侵入性检查/治疗结束。Processscope:Beginningatimmediatelybeforethestartofthesurgeryorinvasiveexamination/treatmentandendingatthecompletionofthesurgeryorinvasiveexamination/procedure.

4.定义Definition

4.1指进行外科手术或侵