手术安全核查执行督查表模板

手术安全核查执行督查表模板引言手术安全是医疗质量与患者安全的核心环节，而手术安全核查制度则是保障这一核心环节的关键抓手。为确保手术安全核查制度在临床实践中得到不折不扣的执行，及时发现并纠正执行过程中存在的偏差，持续改进核查质量，特制定本手术安全核查执行督查表模板。本模板旨在为医院质量管理部门、手术室及相关临床科室提供一个结构化、可操作的工具，以客观评估手术安全核查的执行情况，促进安全文化的落地生根。手术安全核查执行督查表督查日期：________年____月____日督查时段：________（上午/下午/全天）督查区域：________手术室（如有多间，请注明具体手术间或抽查范围）督查员：________被督查科室/团队：________序号核查时机督查项目核查要点标准要求执行情况(√：符合□：部分符合×：不符合N/A：不适用)未达标情况描述及改进建议:---:-------------:-------------------------------------------:---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------:------------------------------------------------------------------------------------------------------:------------------------------------------------------:--------------------------------------------------------------------------------------**术前核查**1.1**患者接入手术室前/入手术间后**患者身份确认1.病房护士与手术室护士交接时，是否共同核对患者信息？2.核对内容是否至少包括姓名、住院号/ID、出生日期？3.是否主动询问患者姓名？4.病历、手术通知单、腕带信息是否一致？严格执行双人核对，信息完全一致，主动确认患者身份。□√□□□×□N/A1.2手术部位与标识确认1.是否核对手术通知单上的手术部位？2.患者手术部位皮肤是否有清晰、正确的标识？3.标识是否由手术医生或其授权人员完成？4.护士是否参与确认手术部位标识？手术部位清晰标识，与手术通知单一致，多方共同确认。□√□□□×□N/A1.3手术方式确认1.是否与患者（或授权家属）及病历核对手术名称和方式？2.手术知情同意书是否签署完整、规范？手术方式明确，患者/家属知情同意，文书完整。□√□□□×□N/A1.4术前准备1.术前禁食水时间是否符合要求？2.术前皮肤准备、过敏史、输血前检查、相关辅助检查（如影像学资料）是否完备并确认？3.术前用药（如抗生素皮试、术前针）是否按医嘱执行？各项术前准备符合诊疗规范及医嘱要求。□√□□□×□N/A1.5**麻醉诱导前****三方核查启动**1.是否由麻醉医师主导，手术医师、巡回护士共同参与？2.是否在患者麻醉诱导开始前暂停所有操作，进行集中核查？三方必须在场，在规定时间点启动并暂停操作进行核查。□√□□□×□N/A1.6患者身份、手术部位、手术方式再次确认1.三方共同核对患者姓名、住院号/ID、手术名称、手术部位（包括左/右）？2.是否再次确认手术部位标识？信息准确无误，三方达成一致。□√□□□×□N/A1.7麻醉相关核查1.麻醉方式选择是否适宜？麻醉计划是否告知患者（或家属）？2.麻醉设备、监护仪、药品（特别是高危药品）是否准备就绪并核对？3.患者过敏史、NPO状态是否再次确认？4.ASA分级、气道评估等是否完成？麻醉准备充分，风险评估到位，药品设备核对无误。□√□□□×□N/A1.8手术风险评估与预案1.手术医生是否确认手术风险及主要步骤？2.预计失血量、特殊器械、血制品准备是否确认？对手术风险有清晰认识，必要预案已准备。□√□□□×□N/A**术中核查**2.1**手术开始前****三方核查确认**1.是否由手术医师主导，麻醉医师、巡回护士共同参与？2.是否在手术切口开始前暂停所有操作，进行最终核查？三方必须在场，在规定时间点启动并暂停操作进行核查。□√□□□×□N/A2.2最终确认1.患者身份、手术名称、手术部位（左/右）最终确认。2.手术知情同意书、麻醉同意书等法律文书是否完备？3.术前预防性抗生素是否在切皮前规定时间内使用？4.手术用物（如植入物、特殊器械）是否与手术计划相符并核对？所有关键信息最终确认无误，文书齐全，抗生素使用规范，物品核对准确。□√□□□×□N/A2.3手术团队沟通手术医生是否与团队成员明确手术关键步骤、潜在风险及应对措施？关键信息有效传递，团队成员理解一致。□√□□□×□N/A**术后核查**3.1**患者离开手术室前**手术记录与物品核对1.手术医生、护士是否共同核对术中植入物的类型、数量、规格，并记录？2.手术器械、纱布、缝针等清点是否准确无误？3.手术标本是否按规定处理、标识并送检？植入物、物品清点准确记录，标本处理规范。□√□□□×□N/A3.2患者状况与信息交接1.患者生命体征是否平稳，麻醉苏醒状态是否符合转出标准？2.手术室护士与复苏室/病房护士交接时，是否清晰、准确地传递患者信息（包括手术情况、术中用药、输血、引流、皮肤情况、术后注意事项等）？患者状况评估准确，交接信息完整、清晰、准确。□√□□□×□N/A3.3术后医嘱与文书术后即时医嘱是否开具？手术记录是否及时、准确、完整？医嘱及时，记录规范。□√□□□×□N/A**通用项目**4.1**全过程**核查表填写规范1.手术安全核查表是否按要求逐项填写？2.填写是否清晰、完整、无遗漏？3.相关人员是否签名？表格填写规范，信息完整，签名齐全。□√□□□×□N/A4.2团队协作与沟通核查过程中，团队成员是否积极参与，沟通是否有效、顺畅？团队协作良好，沟通无障碍。□√□□□×□N/A4.3特殊情况记录对于核查中发现的问题或特殊情况，是否有记录并及时处理？问题及时记录、上报并追踪整改。□√□□□×□N/A督查总结与建议：*总体评价：(请根据督查情况进行简要概括，例如：本次督查总体情况良好，大部分项目均能按标准执行；或存在XX方面问题，需重点改进等)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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