Authors

Zulema Díaz-García1, Rosa María Rodríguez Medina2

Position

1Maestra en Epidemiología y Administración de los Servicios de Salud. Subdirección de Enfermería. Hospital Regional de Alta Especialidad del Bajío. León (México) 2Doctora en Ciencias Médicas. Departamento de Enfermería y Obstetricia León. Universidad de Guanajuato. León (México)

Contact address

Rosa María Rodríguez Medina. Bosque Limonero, 104-Fracc. El Dorado. 37590 León, Guanajuato (México).

Contact email: anidem_2_2@hotmail.com

Abstract

Surgical care is a comprehensive part of medical care throughout the world, and even though it can prevent the loss of a limb and even life, it is also associated with a significant risk of complications and death. Previous studies coincide in stating that up to 50% of the incidence of complications or adverse events in surgical patients can be avoidable by the implementation of effective preventive measures. This led to the Surgical Safety Checklist published by the World Health Organization (WHO), and other specific checklists that formalize and coordinate individual and shared responsibilities within a team during the surgical process. The present article evaluates the reorganization of record formats, encouraging the critical analysis of information, promoting the creative ability of Nursing professionals, and complying with current legislation in order to prevent adverse events associated with surgical procedures in a tertiary institution. The nursing clinical record was designed considering the recommendations of a panel of experts in the matter. The record was conducted before, during and after surgery, encouraging the critical analysis of the information and offering the possibility to monitor the entire surgical process. This proposal for improvements allowed to identify avoidable risk situations, and to plan improvement and training actions, thus promoting communication within the care team and promoting the development of Nursing professionals.

Versión en Español

Título:

Formato de registro clínico de Enfermería para mejorar la seguridad en el paciente quirúrgico