Inadequate completion of surgical data for patient safety: opinion of health professionals




Surgical Procedures, Operative; Checklist; Hospitals; Patient Safety.


Objective: to investigate variables related to inadequate completion of surgical data for patient safety in the hospital setting in the opinion of health professionals. Methods: retrospective study in 180 medical records of surgical patients in a public hospital and application of a structured questionnaire to caregivers responsible for filling out the surgical data of patients. Descriptive statistical analysis was performed. Results: the medical records showed incomplete surgical records in the preoperative period (61%), intraoperative period (66%) and immediate postoperative period (87%). Professionals reported not knowing the protocol for safe surgery (62%) and the institution's surgical safety form (68%), 87% were not trained to use the intraoperative checklist, 66% considered the number of staff inadequate and 55% considered communication ineffective. Conclusion: in the opinion of health professionals, insufficient professional knowledge, lack of training, inadequate staffing and ineffective communication may be related to inadequate completion of surgical data and patient safety.


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How to Cite

Almeida, A. C. S., Andrade, L. A., Rocha, H. M. do N., Menezes, A. F. de, Santana, I. T. S., Farre, A. G. M. da C., & Santos, J. Y. S. (2021). Inadequate completion of surgical data for patient safety: opinion of health professionals. Rev Rene, 22, e70735.



Research Article

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