4041F Documentation of order for cefazolin OR cefuroxime for antimicrobial prophylaxis (PERI 2)

Name of the Procedure:

Documentation of Order for Cefazolin or Cefuroxime for Antimicrobial Prophylaxis (PERI 2)

Summary

This procedure involves documenting the medical order for administering either Cefazolin or Cefuroxime, which are antibiotics used to prevent infections before, during, and after surgical procedures. The documentation ensures that the antibiotic is prescribed and administered according to medical guidelines.

Purpose

The procedure aims to:

• Prevent surgical site infections (SSIs)
• Ensure that patients receive the appropriate antibiotic prophylaxis in a timely manner to minimize infection risks associated with surgery.

Indications

This procedure is indicated for:

• Patients scheduled to undergo surgical procedures where there is a risk of infection.
• Patients who meet specific criteria for antimicrobial prophylaxis based on surgery type, patient health status, and susceptibility to infections.

Preparation

• No specific preparations are required for this documentation process.
• Medical staff may need to review patient history and surgical plans to ensure appropriate antibiotic selection.

Procedure Description

1. A healthcare provider evaluates the patient’s medical history and the type of surgery planned.
2. The provider decides whether Cefazolin or Cefuroxime is appropriate for antimicrobial prophylaxis.
3. The order for the antibiotic is documented in the patient's medical record.
4. The documentation includes dosage, timing, and route of administration.
5. The order is reviewed and confirmed to be in adherence with clinical guidelines.

Duration

The documentation process typically takes a few minutes for each patient.

Setting

The procedure is performed in:

• Hospitals
• Outpatient surgical centers
• Any healthcare facility where surgical procedures are conducted.

Personnel

• Surgeons
• Anesthesiologists
• Nurses
• Pharmacists

Risks and Complications

• Minimal risk associated with the documentation process itself.
• The main risk involves potential human error in documentation, leading to incorrect antibiotic selection or dosage.

Benefits

• Reduces the risk of postoperative infections.
• Facilitates adherence to clinical guidelines.
• Enhances patient outcomes and safety.

Recovery

The recovery process is not applicable to the documentation procedure itself. Patient recovery pertains to the surgical procedure and the effectiveness of the prophylactic antibiotics.

Alternatives

No direct alternatives to the documentation process, but alternative antibiotics may be considered if the patient has allergies or other contraindications to Cefazolin or Cefuroxime.

Patient Experience

This is an administrative procedure, so patients will generally be unaware of it. They might feel reassured knowing that measures are being taken to prevent infections associated with their surgery.