Surgical Quality & Patient Safety
| ABX 1 | Administration of prophylactic antibiotic within 1 hour before incision (2 hours for Vancomycin or Clindamycin) |
| ABX 2 | Correct prophylactic antibiotic selection based on the procedure type (see Antibiotics Table for specific requirements) |
| ABX 3 | Discontinuance of ALL antibiotics within 24 hours of surgery end time unless there is MD/NP/PA documentation of infection or suspected infection (48 hours for cardiac surgery patients only) |
| BB 1 | Beta-blocker taken within 24 hours of surgery start for all patients on chronic beta-blocker therapy (beta-blocker name, and date time taken must be documented prior to surgery start) |
| BB 2 | Beta-blocker restarted after surgery for all patients on chronic beta-blocker therapy (MD/NP/PA order to restart on the post-operative admission orders RN documentation of beta-blocker administration on post-operative day 1) |
| HAIR | Documentation of appropriate hair removal (clippers only no razors or shaving; "shaved and prepped..." is NOT permitted!) |
| FOLEY | Urinary catheter removal on or before post-operative day 2 unless there is a MD/NP/PA documented reason to extend the catheter. Reason to extend must be written on either post-operative day 1 or day 2. Reason to extend urinary catheter canNOT be written on the day of surgery (i.e. on the post-operative admission orders) |
| SUGAR | Cardiac patients with controlled post-operative blood glucose of ≤ 180 in the time frame of 18 to 24 hours after anesthesia end |
| DVT 1 | Documentation that SCDs were placed during surgery for all procedures ≥ 1 hour. This measure is not required for pediatric, cardiac or vascular surgery patients. RN notation of SCDs on the Operating Room Record is required for all other surgeries. |
| DVT 2 | MD/NP/PA order for the appropriate DVT prophylaxis on the post-operative admission orders (see DVT Prophylaxis Table) unless documentation of a reason for not administering BOTH pharmacological and mechanical VTE prophylaxis |
| DVT 3 | RN administration of the appropraite DVT prophylaxis within 24 hours of surgery end. RN documentation of SCDs and RN administration of pharmacologic agents documented on the medication administration record (MAR). |