10 Surgical Services

W.

During the pre-procedure time out, the following items are verified:

1. Patient identification.

2. Intended procedure.

3. Correct surgical site.

4. All equipment necessary for performing the scheduled procedure is immediately available in the operating/procedure room.

5. Any implantable devices intended to be used during the procedure are prepared before the procedure and available.

Notes: 
P&P
Policy: 

J.2.

The design, construction, and equipment comply with applicable state and local codes. 

J.1.

The design and equipment facilitate the physical safety of all persons in the area. 

H.2.

The organization obtains written informed consent from the patient or the patient’s representative before the procedure or surgery is performed. 

H.1.

There is documentation that the necessity or appropriateness of the proposed procedure or surgery, as well as alternative treatment techniques, have been discussed with the patient. 

Q.

High level disinfection processes adhere to equipment and chemical manufacturers’ instructions. 

Z.

The organization follows established protocols for instructing patients in self-care after surgery and provides written instructions to patients.

Notes: 
P&P
Policy: 

Y.

The organization has written guidelines for internal transfer of care from one provider to another. These guidelines address:

1. Information to be transferred about a patient’s care, including treatment/ services, current condition, and any recent or anticipated changes.

2. How the information will be communicated among members of the health care team.

Notes: 
n/a

N.13.

Fire risks are identified and minimized, and staff members are prepared to address fire hazards, if necessary.

Notes: 
P&P

F.

A written policy is in place for the risk assessment and prevention practices relating to deep vein thrombosis, when appropriate.

Location: 
P&P manual
Policy: 
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