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The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. [1] The checklist serves to remind the surgical team of important items to be performed before and after the surgical procedure in order to reduce adverse events such as surgical site infections or retained instruments. [1]
The Surgical Care and Outcomes Assessment Program (SCOAP) is a clinician-led, performance benchmarking and quality improvement (QI) registry for surgical and interventional procedures. [ 1 ] SCOAP was established in 2005 through a grassroots effort of Washington State's surgical community led by David Flum, MD, MPH, and the state chapter of the ...
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
"High risk procedures or medical specialties are responsible for most avoidable adverse events". Although some mistakes, such as in surgery, are easier to notice, errors occur in all levels of care. [47] Even though complex procedures entail more risk, adverse outcomes are not usually due to error, but to the severity of the condition being ...
The informed consent doctrine is generally implemented through good healthcare practice: pre-operation discussions with patients and the use of medical consent forms in hospitals. However, reliance on a signed form should not undermine the basis of the doctrine in giving the patient an opportunity to weigh and respond to the risk.
Preanesthetic assessment (also called preanesthesia evaluation, pre-anesthesia checkup (PAC) or simply preanesthesia) is a medical check-up and laboratory investigations done by an anesthesia provider or a registered nurse before an operation, to assess the patient's physical condition and any other medical problems or diseases the patient might have. [1]
Other assessment tools may focus on a specific aspect of the patient's care. For example, the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the "fifth vital sign".
A trial master file contains essential documents for a clinical trial that may be subject to regulatory agency oversight. In the European Union (EU), TMFs have a different definition and set of requirements than in the US.
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