Operation theater -SOP

Procedure: Preparation of the patient -

1.Sterilized instruments and linen collected and arranged in respective OTs from CSSD, on the previous night

2.All OTs checked for readiness for surgery by night staff.

3.Anaesthesia trolley checked and drugs drawn up in the morning by OT technician.

4.Anaesthesia machines, ventilators, central gas supply and cylinders checked by the OT technician.

5.All sutures needed for surgery listed and taken from OT Pharmacy in the previous evening – OT nurse.

6.List entered into register with date, patient ID, surgery type, and signed

7.Drugs needed for a surgery are listed out by OT technician

8.Entry made in OT Pharmacy register with date, patient ID, surgery type, and signed by Anaesthesiologist.

9.Unused drugs returned to OT Pharmacy, cancelled from Pharmacy register and final billing done on Pharmacy online Billing system

10.Unused sutures returned to OT Pharmacy, cancelled from Pharmacy register and final billing done on Pharmacy online Billing system

11.OT staff should be informed about infected cases (HIV, HBsAg, MRSA) prior to surgery.( During booking the OT that is a day prior to surgery).

12.They should also be informed by concerned person about cancellation of the cases so that they can schedule the OT for other case.

 To Prevent Wrong Procedure/Side/Site and Wrong Patient-

The prevention of wrong site/side/procedure and patient begins with the preoperative evaluation of the patient.

This involves the following activities such as marking of the surgical side,

 1. Verification of patient 

 (a) prior to the shifting of the patient from the ward to the OT

(b) At the time of patient’s entrance to the OT suite and

 (c)  Prior to the initiation of the procedure inside the theatres

2. Marking of the surgery site on the previous evening.

3. Wrist identification band should be matched with patient records just prior to the surgery.

  To Transfer Patient to Operation Theatre:

1. Prior to the transfer of the patient the ward nurse informs the OT nurse about the patient details and confirms the scheduled time for surgery forty five minutes prior to the scheduled time of surgery.
2. The ward nurse prior to the transfer of the patient will ensure that the nurse’s preoperative checklist is dully filled and all the patient details as required by the surgeons are arranged in the proper order with signature and date.
3. The patient is transferred to the OT as per the hospital’s policy.
4. Jewellery & valuables must be given to the relatives and sign should be taken.
5. Dentures should be removed prior to surgery.
6. Under garments to be removed before OT.
7. Confirm all metallic ornaments are removed.

  Receiving of patient and immediate preoperative assessment:

a. The patient is received in the preoperative patient holding area of the theatre by the nurse.

b. The OT nurse scrutinizes the patient’s details and checks the preoperative nursing Checklist filled by the ward nurse to ensure the patients preparedness and confirms the patient’s identity as per the bed head ticket.

c. The patient is transferred to the operating rooms where the concerned surgeon and anaesthesiologist undertake immediate preoperative evaluation.

Time Out

To prevent the accidental retention of surgical items in the patient body policy on time out will be followed

a. OT nurse will be responsible for the process of time out

b. All the items which are used for the procedure will be documented.

c. These items will be written on the white/black board in the OT.

d. All the items are ticked back once the procedure is over.

Items which needs to be taken care off

• Surgical Items [Scalpel, Scissors, retractors, artery forceps etc]
• Gauge pieces
• Bandages  etc

Review frequency of this document

This document shall be reviewed on an annual basis, and necessary changes made in the document, if required.

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