Abstract
to identify adherence to the safe surgery checklist from its filling out in a general referral hospital in the interior of Minas Gerais state, as well as to verify factors associated with its use. this is a retrospective, documentary, cross-sectional study with a quantitative approach. Data collection was performed through a retrospective review of medical records of patients undergoing surgery within one year. Patients of all specialties, aged 18 years or older, and with hospitalization period equal to or greater than 24 hours were included. The probabilistic sample was composed of 423 cases. the checklist was present in 95% of the medical records. However, only 67.4% of them were completely filled out. The presence of the checklist in the medical record was significantly associated with the anesthetic risk of the patient. There was no difference in the filling out percentage among the three checklist moments: before anesthetic induction (sign in), before surgical incision (time out or surgical pause), and before the patient leaves the operating room (sign out). There were also no significant differences regarding the filling out percentage of the surgeon's responsibility items. Considering the surgical procedure performed, inconsistencies were found in the laterality item. despite the high percentage of medical records with checklist, the presence of incompleteness and inconsistency may compromise the expected results in the safety of the surgical patient.
Highlights
Surgical treatment is an essential therapeutic modality for health care, adding a progressive technological advance that provides cure for many diseases, besides reducing disabilities and the risk of deaths[1,2]
In the context of concern for patient safety in healthcare organizations, the safe surgery CL emerges as a tool with the potential to coordinate surgical care, promote team unity, stimulate the development of a safety culture, and contribute to reducing complications[19]
The results found here showed that the CL was present in the vast majority of the medical records (95%), suggesting that the surgical team endeavored to use it
Summary
Surgical treatment is an essential therapeutic modality for health care, adding a progressive technological advance that provides cure for many diseases, besides reducing disabilities and the risk of deaths[1,2]. Surgical procedures provide great benefits to patients, safety failures may cause considerable damages, resulting in temporary or permanent disabilities and even deaths[1]. Literature indicates that the occurrence of damages associated with surgery is frequent and produces more serious consequences than those observed in clinical care[3,4]. International studies have demonstrated that the risk of having an adverse event (AE) is higher among patients who have undergone surgery when compared to patients with clinical hospitalization[5,6]. Some incidents represent unacceptable surgical complications, such as surgery performed on the wrong patient or site, unintended foreign body retention within a surgical site after the end of the procedure, and intraoperative or immediate postoperative death in patients previously classified as low-risk for complications and death[7]
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