The activity of a health facility implies a high error risk level, above all in the surgical ambit where. Actions and behaviour must be planned and shared to prevent accidents during surgeries and to guarantee success. In comparison with the other sectors, the operating theatre is characterized by technical and service complexity and a lot of factors, like the huge amount of involved professional
workers, patients’ conditions and information quantity required, the high technological level applied to the anesthesia surgical techniques. The surgical unit is a very complex reality. For this reason, has been necessary the realization of an instrument able to reduce the possibility of error, to make
information transmission easier from and to the surgical unit and to underline the specificness of
nursing branch. In 2009, in the surgical unit in Carpi, was created a working team to set up a nursing record with the aim of planning, registering, managing, evaluating, documenting the personalized assistance towards the patient, before, during and after surgery. The nursing record, in the surgical sector in Carpi, is the concrete proof of the daily actions, the expression of professional independence , nursing work and care process. It’ s an available instrument to ensure patient’ s safety, effective communication and care continuity, during the post-surgery period. The nursing record is also characterized by a correct and exhaustive information about all that concerns the patient(operating table, implanted material, gauze swabs count…)specifying its function and the importance of all performed controls.
