Surgical checklists: a systematic review of impacts and implementation

Staff attitudes to and compliance with the use of a surgical safety checklist

OBJECTIVES

To investigate staff attitudes to the use of a surgical safety checklist in a small animal operating room and to gain insight into barriers to use.

MATERIALS AND METHODS

A questionnaire was designed and used to assess attitudes of 36 operating room personnel to the checklist. The checklist was retrospectively audited on 984 patients over an 8-month period to investigate compliance.

RESULTS

Responses were obtained from 100% of operating room personnel. Attitudes to the checklist were positive, with 83.4% agreeing that it improved teamwork and 100% agreed that the checklist improved patient safety, reduced error and was best practice. Most personnel (94%) believed that a completed checklist was used for every procedure. Several barriers were highlighted, including issues of hierarchy and team-working and lack of training. 984 checklists were used during the study period with 83 (8.4%) being fully completed.

CLINICAL SIGNIFICANCE

Surgical safety checklists have potential to improve patient safety in veterinary operating rooms. However, appropriate design and implementation are critical and surgeons should endeavour to support checklist use.

Report of a Quality Improvement Program for Reducing Postoperative Complications by Using a Surgical Risk Calculator in a Cohort of General Surgery Patients

PURPOSE

The study investigates whether postoperative complications in elective surgery can be reduced by using a risk calculator via raising the awareness of the surgeon in a preoperative briefing. Postoperative complications like wound infections or pneumonia result in a high burden for healthcare systems. Multiple quality improvement programs address this problem like the ACS NSQIP Surgical Risk Calculator^® (SRC).

METHODS

To determine whether the preoperative usage of the SRC could reduce inpatient postoperative complications, two groups of 832 patients each were compared using propensity score matching. The SRC was employed retrospectively in the period 2012/2013 in one group ("Retro") and prospectively in the other group ("Prosp") in the period 2014/2015. Actual inpatient postoperative complications were classified by SRC complication categories and compared with the Clavien-Dindo complication classification system (Dindo et al. in Ann Surg 240:205-213, 2004).

RESULTS

Comparing SRC "serious complication" and SRC "any complication," a nonsignificant increase in the "Prosp"-group was apparent (serious complication: 6.6% vs. 8.5%, p = 0.164; any complication: 8.5% vs. 9.7%, p = 0.444).

CONCLUSION

Use of the SRC neither reduces inpatient postoperative complications nor the severity of complications. The calculations of the SRC rely on a 30-day postoperative follow-up. Poor sensitivity and medium specificity of the SRC showed that the SRC could not make accurate predictions in a short follow-up time averaging 6 days. Alternatively, since the observed complication rate was low in our study, in an environment of already highly implemented risk management tools, reductions in complications are not easily achieved.

Perceived barriers to multiprofessional team briefings in operating theatres: a qualitative study

OBJECTIVES

This study investigates perceived barriers towards the implementation of multiprofessional team briefings (MPTB) in operating theatres, as well as ways to overcome these perceived barriers. Previous research shows that MPTB can enhance teamwork and communication, but are underused in operating theatres. By adopting a multilevel systems perspective, this study examines perceived barriers and solutions for MPTB implementation.

DESIGN

Participants completed open-ended survey questions. Responses were coded via qualitative content analysis. The analysis focused on themes in the responses and the systems level at which each barrier and solution operates.

SETTING

Four tertiary hospitals in Australia.

PARTICIPANTS

103 operating theatre staff, including nurses, surgeons, anaesthetists, technicians and administrators.

RESULTS

Participants identified barriers and solutions at the organisational (15.81% of barriers; 74.10% of solutions), work group (61.39% of barriers; 25.09% of solutions) and individual level (22.33% of barriers; 0% of solutions). Of all the perceived barriers to MPTB occurrence, a key one is getting everyone into the room at the same time . Matching of perceived barriers and solutions shows that higher systems-level solutions can address lower level barriers, thereby showing the relevance of implementing such wider reaching solutions to MPTB occurrence (including work practices at occupational level and above) as well as addressing more local issues.

CONCLUSIONS

Successful MPTB implementation requires changes at various systems levels. Practitioners can strategically prepare and plan for systems-based strategies to overcome barriers to MPTB implementation. Future research can build on this study's findings by directly examining higher systems-level barriers and solutions via detailed case analyses.

The cost of operating room delays in an endourology center

INTRODUCTION

This study sought to characterize delays and estimate resulting costs during nephrolithiasis surgery.

METHODS

Independent observers documented delays during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) procedures. Fifty index cases over a period of three months was considered sufficient to observe the generalizable trends. Operating room staff, excluding the surgeons, were blinded. Time-related metrics and delays preventing case progression were recorded using a smartphone-accessible data-collection instrument. Delays were categorized as: 1) missing equipment; 2) missing personnel; 3) equipment malfunction; or 4) delay due to case complexity. The first two categories were regarded as preventable and the latter two non-preventable.

RESULTS

Forty URS and 18 PCNL cases were included. There was a total of 56 delays in 35 (65%) cases. Twelve (67%) PCNLs and 23 (58%) URSs had delays (p=0.57). The mean cumulative delay per case was 3.5±3.2 minutes. Pre-start delays (n=17) were 4.5±3.5 minutes on average while intraoperative delays (n=39) were 3.1±2.9 minutes (p=0.167). Delays were evenly spread among the four categories. Thirty-one (55%) delays were preventable (mean 3.7±3.2 minutes) while 25 (45%) were non-preventable (mean 3.2±3.2 minutes) (p=0.58). This translates to $137 per case in preventable costs.

CONCLUSIONS

Preventable operative delays are encountered frequently in nephrolithiasis surgery, translating to significant additional charges and costs. We demonstrate a rationale for the development of improved communication and workflow protocols to increase efficiency in endourological surgeries. Key limitations are the observational nature of the study and sample size.

UC Care Check-A Postoperative Neurosurgery Operating Room Checklist: An Interrupted Time Series Study

BACKGROUND

The effectiveness of neurosurgical operating room (OR) checklists to improve communication, safety attitudes, and clinical outcomes is uncertain.

PURPOSE

To develop, implement, and evaluate a post-operative neurosurgery operating room checklist.

METHODS

Four large academic medical centers participated in this study. We developed an evidence-based checklist to be performed at the end of every adult-planned or emergent surgery in which all team members pause to discuss key elements of the case. We used a prospective interrupted time series study design to assess trends in clinical and cost outcomes. Safety attitudes and communication among OR providers were also assessed.

RESULTS

There were 11,447 neurosurgical patients in the preintervention and 10,973 in the postintervention periods. After implementation, survey respondents perceived that postoperative checklists were regularly performed, important issues were communicated at the end of each case, and patient safety was consistently reinforced. Observed to expected (O/E) overall mortality rates remained less than one, and 30-day readmission rate, length of stay index, direct cost index, and perioperative venous thromboembolism and hematoma rates remained unchanged as a result of checklist implementation.

CONCLUSION

A neurosurgical checklist can improve OR team communication; however, improvements in safety attitudes, clinical outcomes, and health system costs were not observed.

A Systematic Approach to Ventilator Management for the Pediatric Patient During Air Medical Transport

OBJECTIVE

A checklist was developed to improve the ventilator management of pediatric patients for air medical transport with the aim of reducing the percentage of patients outside recommended parameters (no bag valve mask use, peripheral capillary oxygen saturation level > 90%, and end-tidal carbon dioxide level > 35 and < 50 mm Hg) from 41.3% to 20% within 7 months.

METHODS

The checklist was developed based on recommended guidelines. After checklist orientation, its effectiveness was analyzed via chart review for inclusion criteria (> 5 kg and < 18 years) from July 2018 to January 2019. Parameters identified in the aim statement were used to evaluate effectiveness. After transport, a Likert survey concerning the value of the checklist was distributed.

RESULTS

Significant improvements in pediatric ventilator management were noted when teams used the checklist. The rate outside of aim parameters was reduced significantly from 41.3% (n = 92, June 2012-May 2018 preintervention) to 10% (n = 20, July 2018-January 2019 postintervention) after the improvement action was implemented (χ² = 7.01, P = .008). The 5-point Likert survey results (n = 38, 4.68 ± .57) supported teams' improved comfort after checklist implementation.

CONCLUSION

The checklist improved ventilator management proficiency of pediatric patients and the comfort level of air medical teams providing care.

Compliance With Preoperative Elements of the American Society of Colon and Rectal Surgeons Rectal Cancer Surgery Checklist Improves Pathologic and Postoperative Outcomes

BACKGROUND

In 2016, the American Society of Colon and Rectal Surgeons published a rectal cancer surgery checklist composed of the essential elements of preoperative, intraoperative, and postoperative care for patients undergoing rectal cancer surgery.

OBJECTIVE

The purpose of this study was to assess whether compliance with preoperative checklist elements was associated with improved pathologic and 30-day postoperative outcomes after rectal cancer surgery.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study involved North American hospitals contributing to the American College of Surgeons National Surgical Quality Improvement Program.

PATIENTS

Adult patients who underwent elective rectal cancer surgery from 2016 to 2017 were included.

INTERVENTION

The study encompassed checklist compliance with 6 preoperative elements from the checklist.

MAIN OUTCOME MEASURES

Pathologic outcomes (circumferential resection margin status, distal resection margin status, and adequate lymph node harvest ≥12), 30-day surgical morbidity, and length of stay were measured.

RESULTS

In total, 2217 patients were included in the analysis. Individual compliance with the 6 available preoperative checklist items was variable, including 91.3% for pretreatment documentation of tumor location within the rectum, 86.8% for complete colonoscopy, 84.0% for appropriate preoperative stoma marking, 79.8% for appropriate use of neoadjuvant radiotherapy, 76.6% for locoregional staging, and 70.8% for distant staging. Only 836 patients (37.7%) had all 6 checklist elements complete, whereas 1381 (62.3%) did not. Compared with patients without checklist compliance, patients with checklist compliance were younger (60.0 vs 63.0 y; p < 0.001) but otherwise had similar demographic characteristics. On multivariate regression, checklist compliance was associated with lower odds of circumferential resection margin positivity (OR = 0.47 (95% CI, 0.31-0.71); p < 0.001), higher odds of an adequate lymph node harvest ≥12 (OR = 1.60 (95% CI, 1.29-2.00); p < 0.001), reduced surgical morbidity (OR = 0.78 (95% CI, 0.65-0.95); p = 0.01), and shorter length of stay (β = -0.87 (95% CI, -1.51 to -0.24); p = 0.007). The association between checklist compliance and reduced odds of circumferential resection margin positivity remained on sensitivity analysis (OR = 0.61 (95% CI, 0.42-0.88); p = 0.009) when adjusting for neoadjuvant radiation.

LIMITATIONS

This study was limited by its absence of long-term oncologic data and missing variables.

CONCLUSIONS

Compliance with 6 preoperative elements of the American Society of Colon and Rectal Surgeons rectal cancer surgery checklist was associated with significantly improved pathologic outcomes and reduced postoperative morbidity. See Video Abstract at http://links.lww.com/DCR/B80. EL CUMPLIMIENTO CON LOS ELEMENTOS PREOPERATORIOS DE LA LISTA DE VERIFICACIÓN DE CIRUGÍA PARA CÁNCER RECTAL DE LA SOCIEDAD AMERICANA DE CIRUJANOS DE COLON Y RECTO MEJORA LOS RESULTADOS HISTOPATOLÓGICOS Y POSTOPERATORIOS: En 2016, la Sociedad Americana de Cirujanos de Colon y Recto publicó una lista de verificación de cirugía de cáncer de recto que comprende los elementos esenciales de la atención pre, intra y postoperatoria para pacientes sometidos a cirugía de cáncer de recto.Evaluar si el cumplimiento con los elementos preoperatorios de la lista de verificación se asoció con mejores resultados histopatológicos y postoperatorios a 30 días después de la cirugía de cáncer rectal.Estudio de cohorte retrospectiva.Hospitales norteamericanos que contribuyen al Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos.Pacientes adultos que se sometieron a cirugía electiva de cáncer rectal entre 2016 y 2017.Cumplimiento de la lista de verificación con seis elementos preoperatorios de la lista de verificación.Resultados histopatológicos (estado del margen de resección circunferencial, estado del margen de resección distal, cosecha adecuada de ganglios linfáticos ≥12), morbilidad quirúrgica a 30 días y duración de la estadía.En total, 2,217 pacientes fueron incluidos en el análisis. El cumplimiento individual de los seis ítems disponibles de la lista de verificación preoperatoria fue variable: 91.3% para la documentación previa al tratamiento de la localización del tumor dentro del recto, 86.8% para colonoscopía completa, 84.0% para el marcado preoperatorio apropiado del sitio de estoma, 79.8% para el uso apropiado de radioterapia neoadyuvante, 76.6 % para estadificación locorregional y 70.8% para estadificación distante. Solo 836 (37.7%) pacientes tenían los seis elementos de la lista de verificación completos, mientras que 1,381 (62.3%) no. En comparación con los pacientes sin cumplimiento de la lista de verificación, los pacientes con cumplimiento de la lista de verificación eran más jóvenes (60.0 vs. 63.0 años, p <0.001), pero por lo demás tenían características demográficas similares. En la regresión multivariada, el cumplimiento de la lista de verificación se asoció con menores probabilidades de positividad en el margen de resección circunferencial (OR = 0.47; IC del 95%: 0.31-0.71, p <0.001), mayores probabilidades de una cosecha adecuada de ganglios linfáticos ≥12 (OR = 1.60, IC 95% 1.29-2.00, p <0.001), menor morbilidad quirúrgica (OR = 0.78, IC 95% 0.65-0.95, p = 0.01) y menor duración de estadía (β = -0.87, IC 95% -1.51 - - 0.24, p = 0.007). La asociación entre el cumplimiento de la lista de verificación y las probabilidades reducidas de positividad del margen de resección circunferencial se mantuvo en el análisis de sensibilidad (OR = 0.61; IC del 95%: 0.42-0.88, p = 0.009) al ser ajustado con radiación neoadyuvante.Ausencia de datos oncológicos a largo plazo y variables faltantes.El cumplimiento de seis elementos preoperatorios de la lista de verificación de cirugía de cáncer rectal de la Sociedad Americana de Cirujanos de Colon y Recto se asoció con resultados histopatológicos significativamente mejores y una menor morbilidad postoperatoria. Vea el resumen en video en http://links.lww.com/DCR/B80.

Impact of the World Health Organization Surgical Safety Checklist on Patient Safety

The incidence of surgical complications has remained largely unchanged over the past two decades. Inherent complexity in surgery, new technology possibilities, increasing age and comorbidity in patients may contribute to this. Surgical safety checklists may be used as some of the tools to prevent such complications. Use of checklists may reduce critical workload by eliminating issues that are already controlled for. The global introduction of the World Health Organization Surgical Safety Checklist aimed to improve safety in both anesthesia and surgery and to reduce complications and mortality by better teamwork, communication, and consistency of care. This review describes a literature synthesis on advantages and disadvantages in use of surgical safety checklists emphasizing checklist development, implementation, and possible clinical effects and using a theoretical framework for quality of provided healthcare (structure-process-outcome) to understand the checklists' possible impact on patient safety.

National survey of UK Dermatologists demonstrates significant variation in how to obtain consent for dermatological procedures

Consent must be undertaken prior to any dermatological procedure; however, in doing this, the clinician needs to ensure consent is valid and satisfies the principles of determining material risk. We aimed to assess variations in obtaining consent in the UK and understanding of material risk through a nationally distributed survey to members of the British Society for Dermatological Surgery and British Association of Dermatologists. Of 165 responses, we found that written consent was being obtained for all procedures in 73.9% of cases and typically at the time of procedure in the operating room/theatre (78.8%). Fifty-seven per cent of respondents were not familiar with the term 'material risk' and almost one-third were not aware of the Montgomery vs. Lanarkshire ruling, which replaced the Bolam test in 2015. We would encourage readers to be aware of these changes to consent law in the UK and how it might affect their approach to obtaining consent.

Variability in the use of pulse oximeters with children in Kenyan hospitals: A mixed-methods analysis

BACKGROUND

Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use.

METHODS AND FINDINGS

We analyzed admissions data recorded through Kenya's Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN's feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups.

CONCLUSIONS

There remain major challenges to implementing pulse oximetry-a cheap, decades old technology-into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized.

Cognitive bias in clinical medicine

Cognitive bias is increasingly recognised as an important source of medical error, and is both ubiquitous across clinical practice yet incompletely understood. This increasing awareness of bias has resulted in a surge in clinical and psychological research in the area and development of various 'debiasing strategies'. This paper describes the potential origins of bias based on 'dual process thinking', discusses and illustrates a number of the important biases that occur in clinical practice, and considers potential strategies that might be used to mitigate their effect.

Development and Evaluation of Novel Electronic Medical Record Tools For Avoiding Bleeding After Percutaneous Coronary Intervention

Background

Bleeding remains the most common complication of percutaneous coronary intervention. Guidelines recommend assessing bleeding risk before percutaneous coronary intervention to target use of bleeding avoidance strategies and mitigate bleeding events. Cedars‐Sinai Medical Center undertook an initiative to integrate these recommendations into the electronic medical record.

Methods and Results

The intervention included a voluntary clinical decision alert to assess bleeding risk before percutaneous coronary intervention, a bleeding risk calculator tool based on the NCDR (National Cardiovascular Data Registry) risk prediction model and, when indicated, a second alert to consider 4 bleeding avoidance strategies. We tested for changes in the use of bleeding avoidance strategies and bleeding event rates by comparing procedures performed before versus after implementation of the electronic medical record–based intervention and with versus without use of the bleeding risk calculator tool. Use of radial access increased (47.6% versus 64.8%; P<0.001) and glycoprotein IIb/IIIa inhibitors decreased (12.8% versus 3.17%; P<0.001) from before to after implementation, though risk‐adjusted bleeding event rates were stable (odds ratio, 0.82; P=0.164), even for high‐risk procedures. Use versus nonuse of the bleeding risk calculator tool was associated with increased radial access and reductions in glycoprotein IIb/IIIa inhibitors, but no change in bleeding events.

Conclusions

Integrating guideline recommendations into the electronic medical record to promote assessments of bleeding risk and use of bleeding avoidance strategies was feasible and associated with changes in clinical practice. Future work is needed to ensure that bleeding avoidance strategies are not overused among lower‐risk patients, and that, for high‐risk patients, the potential benefits of elective percutaneous coronary intervention are carefully weighed against the risk of bleeding.

Developing an intervention around referral and admissions to intensive care: a mixed-methods study

Background

Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

Objectives

To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

Methods

A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.

Results

Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

Limitations

Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.

Conclusions

Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.

Future work

Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.

Study registration

The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.

Funding

The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

Effectiveness of a multicomponent safe surgery intervention on improving surgical quality in Tanzania's Lake Zone: protocol for a quasi-experimental study

INTRODUCTION

Effective, scalable strategies for improving surgical quality are urgently needed in low-income and middle-income countries; however, there is a dearth of evidence about what strategies are most effective. This study aims to evaluate the effectiveness of Safe Surgery 2020, a multicomponent intervention focused on strengthening five areas: leadership and teamwork, safe surgical and anaesthesia practices, sterilisation, data quality and infrastructure to improve surgical quality in Tanzania. We hypothesise that Safe Surgery 2020 will (1) increase adherence to surgical quality processes around safety, teamwork and communication and data quality in the short term and (2) reduce complications from surgical site infections, postoperative sepsis and maternal sepsis in the medium term.

METHODS AND ANALYSIS

Our design is a prospective, longitudinal, quasi-experimental study with 10 intervention and 10 control facilities in Tanzania's Lake Zone. Participants will be surgical providers, surgical patients and postnatal inpatients at study facilities. Trained Tanzanian medical data collectors will collect data over a 3-month preintervention and postintervention period. Adherence to safety as well as teamwork and communication processes will be measured through direct observation in the operating room. Surgical site infections, postoperative sepsis and maternal sepsis will be identified prospectively through daily surveillance and completeness of their patient files, retrospectively, through the chart review. We will use difference-in-differences to analyse the impact of the Safe Surgery 2020 intervention on surgical quality processes and complications. We will use interviews with leadership and surgical team members in intervention facilities to illuminate the factors that facilitate higher performance.

ETHICS AND DISSEMINATION

The study has received ethical approval from Harvard Medical School and Tanzania's National Institute for Medical Research. We will report results in peer-reviewed publications and conference presentations. If effective, the Safe Surgery 2020 intervention could be a promising approach to improve surgical quality in Tanzania's Lake Zone region and other similar contexts.

The Need for Surgical Safety Checklists in Neurosurgery Now and in the Future-A Systematic Review

Safety checklists have been studied among various surgical patient groups, but evidence of their benefits in neurosurgery remains sparse. Since the implementation of the World Health Organization's Surgical Safety Checklist, their use has become widespread. The aim of this review was to systematically review the state of the literature on surgical safety checklists in neurosurgery. Also, in the new era of robotics and artificial intelligence, there is a need to re-evaluate patient safety procedures in neurosurgery. A systematic review was conducted on PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials, Embase, and MEDLINE for articles published between 2008 and 2016 using MeSH (medical subject heading) terms and keywords describing postoperative complications and surgical adverse events, and some additional searches were carried out until January 2019. Twenty-six original studies or reviews were eligible for this review. They were categorized into studies with patient-related outcomes, personnel-related outcomes, or previous reviews. Checklist use in neurosurgery was found to reduce hospital-acquired infectious complications and to enhance operating room safety culture. Checklists seem to improve patient safety in neurosurgery, although the amount of evidence is still limited. Despite their shortcomings, checklists are here to stay, and new research is required to update checklists to meet the requirements of the transforming working environment of the neurosurgery operating room.

[Safety Walk Rounds - Clinical unit visits with a focus on patient safety]

Safety Walk Rounds - Clinical unit visits with a focus on patient safety Abstract. Background: Safety Walk Rounds are a promising strategy to promote the safety culture and optimising patient safety. The purpose of this study was to explore patient safety attributes in various clinical areas including recommendations for improvement and leadership support. Methods: Safety Walk Rounds were conducted by the chief patient safety officer based on a structured questions format to open patient safety dialogues with clinicians at the ward level. Field notes were utilized for thematic analyses and topic categorization. Results: A total of 187 clinicians (64 % nursing staff, 19 % physicians, 17 % other health care professionals) participated on the Safety Walk Rounds. The discussion findings are presented in five categories: Events & circumstances (potentially) harmful for patients; safety culture; need for local action, as well as the need for leadership support to provide safe care. Conclusion and outlook: Safety Walk Rounds across the hospitals' clinical areas delivered insight into patient safety issues and safety culture with its caregiver's engagement to provide safe care as well as action points for future improvement including leadership support.

Improving patient safety in the endoscopy unit: utilization of remote video auditing to improve time-out compliance

BACKGROUND AND AIMS

Patient and procedure verification, or the time-out process (TOP), is considered one of the most vital components of patient safety. It has long been a focus of intervention in the surgical community and recently was incorporated into the American Society for Gastrointestinal Endoscopy guidelines for safety in the GI endoscopy unit. The TOP has had limited attention in the endoscopy literature but remains an area for improvement in clinical endoscopy practice. The aim of this study was to identify barriers and improve TOP compliance rates in our endoscopy unit using remote video auditing (RVA).

METHODS

This was a single-center, prospective, pilot initiative in an endoscopy unit at a tertiary care academic medical center. Video cameras with offsite monitoring were installed in each procedure room in our endoscopy suite in November 2016. Baseline TOP compliance rates were audited with RVA over a 2-month period. A multidisciplinary quality improvement team reviewed the data, identified barriers to the TOP, and implemented actionable items in January 2017. TOP compliance rates were again monitored via RVA, and data were collected through October 2018. Pre- and postintervention TOP compliance rates were compared.

RESULTS

Over the baseline period, 692 procedures were audited and TOP compliance documented. Baseline TOP compliance rate was 69.6%. Identifiable barriers to TOP compliance included a lack of designated team member to lead TOP, inconsistent documentation of TOP, irrelevant safety checklist items not applicable to endoscopic procedures, and lack of patient safety culture. Actionable items implemented in response to these barriers included designation of a TOP leader, visual indication of initiation of TOP, creation of a concise endoscopy-specific safety checklist, and formal notification/education of the entire endoscopy team. Postintervention TOP compliance rates were then audited from January 2017 to October 2018 and included 12,008 procedures. The mean TOP compliance rate significantly improved from baseline (95.3% vs 69.6%; 95% confidence interval, 22.4-29.3; P < .0001). Additionally, the improvement was maintained throughout the entire postintervention observation period.

CONCLUSIONS

TOP compliance rates significantly improved in our endoscopy unit through the use of RVA and implementation of 4 actionable items. Future studies should evaluate the reproducibility of this method in other endoscopy units.

Development and Feasibility Testing of a Device Briefing Tool and Training to Improve Patient Safety During Introduction of New Devices in Operating Rooms: Best Practices and Lessons Learned

BACKGROUND

Introducing new surgical devices into the operating room (OR) can serve as a critical opportunity to address patient safety. The effectiveness of OR briefings to improve communication, teamwork, and safety has not been evaluated in this setting.

METHODS

Ariadne Labs and Johnson and Johnson (J&J) collaborated to develop and assess an intervention including a Device Briefing Tool (DBT) and novel multidisciplinary team training for clinicians (surgeons and nurses) around the introduction of a new device in the OR. J&J sales representatives trained clinicians to use the DBT, a communication tool to improve patient safety when a new device is used for the first time. Surveys were administered to representatives (n = 10), surgeons (n = 15), and nurses (n = 30) at the baseline, after trainings, and after using the DBT in an operation at six different Thai hospitals.

RESULTS

Familiarity with the Surgical Safety Checklist (SURGICAL SAFETY CHECKLIST) varied but increased post-training. Regarding trainings, 90% of representatives felt they very much or completely met all learning objectives but 50% felt only slightly prepared to train clinicians on using DBT. Post-training, clinician confidence in using a new device rose from 47 to 85%. Regarding the DBT, 90% of clinicians felt confident using it and reported they were very likely to use it in the future. Overall, over 90% of all clinicians and representatives felt safe having surgery in their hospitals.

CONCLUSIONS

There is high acceptability and feasibility of the multidisciplinary trainings and the DBT among representatives and clinicians, albeit in a limited number of participants from a small number of institutions.

Does Attending Surgeon Presence at the Preinduction Briefing Improve Operating Room Efficiency?

OBJECTIVE

To examine if attending surgeon presence at the preinduction briefing is associated with a shorter time to incision.

STUDY DESIGN

Retrospective cohort study and survey.

SETTING

Tertiary academic medical center.

SUBJECTS AND METHODS

A retrospective cohort study was conducted of 22,857 operations by 141 attending surgeons across 12 specialties between August 3, 2016, and June 21, 2018. The independent variable was attending surgeon presence at the preinduction briefing. Linear regression models compared time from room entry to incision overall, by service line, and by surgeon. We hypothesized a shorter time to incision when the attending surgeon was present and a larger effect for cases with complex surgical equipment or positioning. A survey was administered to evaluate attending surgeons' perceptions of the briefing, with a response rate of 68% (64 of 94 attending surgeons).

RESULTS

Cases for which the attending surgeon was present at the preinduction briefing had a statistically significant yet operationally minor reduction in mean time to incision when compared with cases when the attending surgeon was absent. After covariate adjustment, the mean time to incision was associated with an efficiency gain of 1.8 ± 0.5 minutes (mean ± SD; P < .001). There were no statistically significant differences in the subgroups of complex surgical equipment and complex positioning or in secondary analysis comparing service lines. The surgeon was the strongest confounding variable. Survey results demonstrated mild support: 55% of attending surgeons highly prioritized attending the preinduction briefing.

CONCLUSION

Attending surgeon presence at the preinduction briefing has only a minor effect on efficiency as measured by time to incision.

Why is reporting quality improvement so hard? A qualitative study in perioperative care

OBJECTIVES

Quality improvement (QI) may help to avert or mitigate the risks of suboptimal care, but it is often poorly reported in the healthcare literature. We aimed to identify the influences on reporting QI in the area of perioperative care, with a view to informing improvements in reporting QI across healthcare.

DESIGN

Qualitative interview study.

SETTING

Healthcare and academic organisations in Australia, Europe and North America.

PARTICIPANTS

Stakeholders involved in or influencing the publication, writing or consumption of reports of QI studies in perioperative care.

RESULTS

Forty-two participants from six countries took part in the study. Participants included 15 authors (those who write QI reports), 12 consumers of QI reports (practitioners who apply QI research in practice), 11 journal editors and 4 authors of reporting guidelines. Participants identified three principal challenges in achieving high-quality QI reporting. First, the broad scope of QI reporting-ranging from small local projects to multisite research across different disciplines-causes uncertainty about where QI work should be published. Second, context is fundamental to the success of a QI intervention but is difficult to report in ways that support replication and development. Third, reporting is adversely affected by both proximal influences (such as lack of time to write up QI) and more distal, structural influences (such as norms about the format and content of biomedical research reporting), leading to incomplete reporting of QI findings.

CONCLUSIONS

Divergent terminology and understandings of QI, along with existing reporting norms and the challenges of capturing context adequately yet succinctly, make for challenges in reporting QI. We offer suggestions for improvement.

Identifying and resolving the frustrations of reviewing the improvement literature: The experiences of two improvement researchers

Background and aims

Summarising quality improvement (QI) research through systematic literature review has great potential to improve patient care. However, heterogeneous terminology, poor definition of QI concepts and overlap with other scientific fields can make it hard to identify and extract data from relevant literature. This report examines the compromises and pragmatic decisions that undertaking literature review in the field of QI requires and the authors propose recommendations for literature review authors in similar fields.

Methods

Two authors (EJ and JF) provide a reflective account of their experiences of conducting a systematic literature review in the field of QI. They draw on wider literature to justify the decisions they made and propose recommendations to improve the literature review process. A third collaborator, (WC) co-created the paper challenging author’s EJ and JF views and perceptions of the problems and solutions of conducting a review of literature in QI.

Results

Two main challenges were identified when conducting a review in QI. These were defining QI and selecting QI studies. Strategies to overcome these problems include: select a multi-disciplinary authorship team; review the literature to identify published QI search strategies, QI definitions and QI taxonomies; Contact experts in related fields to clarify whether a paper meets inclusion criteria; keep a reflective account of decision making; submit the protocol to a peer reviewed journal for publication.

Conclusions

The QI community should work together as a whole to create a scientific field with a shared vision of QI to enable accurate identification of QI literature. Our recommendations could be helpful for systematic reviewers wishing to evaluate complex interventions in both QI and related fields.

Quality Initiative to Improve Compliance With Perioperative Anticoagulation

PURPOSE

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in gynecologic oncology surgical patients. Many centers use neuraxial analgesia (NA), which affects the timing of prophylactic anticoagulation. In 2012, we determined that the rate of VTE in patients undergoing laparotomy with NA was higher than in those who received alternative pain control. In addition, compliance with preoperative anticoagulation guidelines was only 40%. We undertook a quality initiative (QI) project to increase compliance to 80% in NA cases and maintain 90% in non-NA cases.

METHODS

A multidisciplinary working group designed and deployed a QI intervention bundle. Compliance was defined as the receipt of a prophylactic dose of anticoagulant within 1 hour after NA or before skin incision regardless of anesthesia type. Data were abstracted from the medical record after the study period. Cases from the year before QI were used for comparison. Primary outcome was compliance and secondary outcome was the rate of VTE.

RESULTS

One hundred women were treated under the QI project and 182 historical cases (HCs) were used for comparison. Overall compliance improved (96% QI v 73% HC; P < .001). This difference was marked in cases with NA (95% QI v 40% HC; P < .001) and remained stable in non-NA cases (97% QI v 91% HC; P = .29). The overall rate of VTE, independent of anesthesia type, remained unchanged (2.1% HC v 0% QI; P = .3).

CONCLUSION

Relatively simple and inexpensive initiatives to improve routine processes within the surgical pathway are feasible and attract staff participation. Such efforts are likely to translate into greater levels of patient safety.

Scaling Safety: The South Carolina Surgical Safety Checklist Experience

Proven patient safety solutions such as the World Health Organization's Surgical Safety Checklist are challenging to implement at scale. A voluntary initiative was launched in South Carolina hospitals in 2010 to encourage use of the checklist in all operating rooms. Hospitals that reported completing implementation of the checklist in their operating rooms by 2017 had significantly higher levels of CEO and physician participation and engaged more in higher-touch activities such as in-person meetings and teamwork skills trainings than comparison hospitals did. Based on our experience and the participation data collected, we suggest three considerations for hospital, hospital association, state, and national policy makers: Successful programs must be designed to engage all stakeholders (CEOs, physicians, nurses, surgical technologists, and others); offering a variety of program activities-both lower-touch and higher-touch-over the duration of the program allows more hospital and individual participation; and change takes time and resources.

Neither magic bullet nor a mere tool: negotiating multiple logics of the checklist in healthcare quality improvement

Over two decades, the checklist has risen to prominence in healthcare improvement. This paper contributes to the debate between its proponents and critics, making the case for an Science and Technology Studies-informed understanding of the checklist that demonstrates the limitations of both the "checklist-as-panacea" and "checklist-as-socially-determined" positions. Attending to the checklist as a socio-material object endowed with affordances that call upon clinicians to act (Allen 2012, Hutchby 2001), the study revisits the efforts of a recent improvement initiative, the Enhanced Peri-Operative Care for High-risk patients trial. Rather than a singularised simple tool, this study discusses four different and relationally enacted logics of the checklist as a stop and check tool, a clinical prompt, an audit tool and a clinical record. Each logic is associated with specific temporality, beneficiaries, relationship with material forms, and interpellates (Law 2002) clinicians to initiate specific actions which can conflict. The paper seeks to make the case for intervention to improve such tools and consciously account for the consequences of their design and materiality and calls for supporting such settings and arrangements in which incoherences collected in tools can be locally negotiated.

Do safety briefings improve patient safety in the acute hospital setting? A systematic review

AIMS

To synthesize current knowledge about the impact of safety briefings as an intervention to improve patient safety.

BACKGROUND

Improving safety in health care remains an ongoing challenge. There is a lack of evidence underpinning safety enhancing interventions.

DESIGN

Mixed method multi-level synthesis.

DATA SOURCES

Four health literature databases were searched (Cinahl, Medline, Scopus and Health Business Elite) from January 2002 - March 2017.

REVIEW METHODS

Thomas and Harden approach to mixed method synthesis.

RESULTS

Following quality appraisal, 12 studies were included. There was significant heterogeneity in study aims, measures, and outcomes. Findings showed that safety briefings achieved beneficial outcomes and can improve safety culture. Outcomes included improved risk identification, reduced falls, enhanced relationships, increased incident reporting, ability to voice concerns, and reduced length of stay.

CONCLUSION

Healthcare leaders should embrace the potential of safety briefings by promoting their effective use whilst allowing for local adaptation.

Thermoregulation protocol implementation for newborns in surgical procedures

OBJECTIVE

To describe the thermoregulation protocol implementation for newborns (NB).

METHODS

An experimental report, conducted at a neonatal unit in Salvador, Bahia, from January 2016 to January 2017. The Plan, Do, Check, Action cycle guided the construction, implementation and applicability of the protocol.

RESULTS

Implementation of the protocol that allowed the reduction of adverse events due to thermal instability during surgical procedures and introduction of new technologies.

CONCLUSION

The protocol could improve and strengthen the care practices related to safe surgery in newborns.

Adherence to the WHO surgical safety checklist: an observational study in a Swiss academic center

Background

The World Health Organization (WHO) Surgical Safety Checklist is used globally to ensure patient safety during surgery. Two years after its implementation in the University Hospital Basel's operating rooms, adherence to the protocol was evaluated.

Methods

This mixed method observational study took place in the surgical department of the University Hospital of Basel, Switzerland from April to August 2017. Data collection was via individual structured interviews with selected OR team members regarding checklist adherence and on-site non-participant observations of Team Time Out and Team Sign Out sequences in the OR. Data were subjected to thematic analysis and descriptive statistics compiled.

Results

Comprehensive local expert interviews indicated that individual, procedural and contextual variables influenced the application of the checklist. Facilitating factors included well-informed specialists who advocated the use of the Checklist, as well as teams focused on the checklist's intended process and on its content. In contrast, factors such as staff insecurity, a generally negative attitude towards the checklist, a lack of teamwork, and hesitance to complete the checklist, hindered its implementation.The checklist's application was evaluated in 104 on-site observations comprising of 72 Team Time Out (TTO) and 32 Team Sign Out (TSO) sections. Adherence to the protocol ranged between 96 and 100% in TTO and 22% in TSO respectively. Lack of implementation of the TSO was mainly due to the absence of one of the key OR team members, who were busy with other tasks or no longer present in the operating room.

Conclusion

The study illustrates factors, which foster and hinder consistent application of the WHO surgical safety checklist namely individual, procedural and contextual. It also demonstrates that the TTO was consistently and correctly applied, while the unavailability of key OR team members at sign-out time was the most common reason for omission or incomplete use of the TSO.

Laboratory Monitoring and Transfusion Guidelines to Influence Care in Patients Undergoing Multilevel Spinal Fusion Surgery

PURPOSE

The purpose of this project was to determine whether the use of the modified Northwestern high risk spine protocol in patients undergoing multilevel spinal fusion surgery would result in improved transfusion practices.

DESIGN

Preimplementation and postimplementation design.

METHODS

A laboratory monitoring and transfusion guideline protocol was implemented in patients undergoing multilevel spinal fusions. Data were collected via a manual retrospective chart review of the electronic medical record before and after implementation of the protocol.

FINDINGS

Laboratory values were monitored at guided intervals. There was a statistically significant (P = .004) decrease in the mean hemoglobin value at which a packed red blood cell transfusion was initiated.

CONCLUSIONS

Through the use of the protocol, laboratory value monitoring provided quantitative data to aid and improve clinical decision making for practitioners in the perioperative period.

Preprocedural checklist for regional anesthesia: impact on the incidence of wrong site nerve blockade (an 8-year perspective)

BACKGROUND

The term "Wrong-Site Surgery (WSS)" is commonly associated with surgical procedures; however, The Joint Commission (TJC) considers any invasive procedure, not just a surgical procedure, performed on the wrong side, at the wrong site, or on the wrong patient to be a WSS. For anesthesia providers, this means that a wrong-site nerve block (WSNB) also constitutes a WSS and would be considered a sentinel event by TJC. In an attempt to combat WSNB, the American Society of Regional Anesthesia and Pain Medicine published guidelines in 2014 recommending the use of a preprocedural checklist before performing regional blocks. The effectiveness of such a checklist, however, to reduce the occurrence of WSNB has not yet been demonstrated. We hypothesized that the introduction of a preprocedural checklist specific for regional anesthesia would be associated with a lower rate of WSNB procedures.

METHODS

A retrospective review was performed to compare the incidence of WSNB 2  years before, to 6  years after the implementation of a preprocedural checklist specific to regional anesthesia.

RESULTS

Prior to checklist implementation, 4 WSNB events occurred during 10 123 procedures (3.95 per 10 000 (95% CI 1.26 to 9.53). Following implementation, WSNB events occurred during 35 890 procedures (0 per 10 000 (95% CI 0 to 0.84)); p=0.0023.

CONCLUSIONS

Implementation of a regional anesthesia specific preprocedural checklist was associated with a significantly lower incidence of WSNB procedures. While prospective controlled studies would be required to demonstrate causation, this study suggests that for regional anesthesia procedures, a preprocedural checklist may positively impact patient safety.

Surgical safety in catheterization laboratory

OBJECTIVE

To describe the process of implanting the surgical safety checklist in a catheterization laboratory (CL).

METHOD

Descriptive case report study about the safety strategies developed in the last six years in a university hospital in the southern region of Brazil.

RESULTS

The six international patient safety goals (IPSG) were incorporated into the care practice in accordance with the hospital's Joint Comission International (JCI) accreditation program, through a continuous process of educational nature. The checklist was adapted considering the characteristics of the unit and the procedures performed.

CONCLUSION

The implementation of the checklist provided the promotion of patient safety, greater staff integration, advances in communication among professionals and the recording of in-room care information.

Surgical safety checklist: benefits, facilitators, and barriers in the nurses' perspective

OBJECTIVE

To identify the benefits, facilitators and barriers in the implementation of the surgical safety checklist, according to the reports of nurses working in the hospital surgical center.

METHOD

Cross-sectional study with 91 nurses in 25 hospitals in two municipalities of Paraná. Between the years 2015 and 2016, two structured instruments were used to collect data. For the analysis, Fisher's exact or Chi-Square test was used.

RESULTS

The implementation of the checklist brought benefits to the patient, surgical team and hospitals. Regarding the facilitators, the results presented a statistically significant difference between the groups in the items offering education (p=0.006) and acceptance by surgeons (p=0.029). In the barriers, the lack of administrative (p=0.006) and management (p=0.041) support, absence of the patient safety nucleus (p=0.005), abruptly introduced list (p=0.001) and absence of education (p<0.001).

CONCLUSION

The evidence generated allowed to identify the benefits, facilitators and barriers in the implementation of the checklist in the national context.

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

BACKGROUND

The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy.

METHODS

In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation.

RESULTS

Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -9·4 (95 per cent c.i. -11·9 to -6·9) per cent; P < 0·001), but the relationship was reversed in low-HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries.

CONCLUSION

Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.

Implementation process of the Surgical Safety Checklist: integrative review

Objective:

to analyze the evidence available in the literature on the process of implementing the Surgical Safety Checklist, proposed by the World Health Organization, in the practice of health services.

Method:

integrative review, the search for primary studies was performed in three relevant databases in the health area, and the sample consisted of 27 studies, which were grouped into three categories.

Results:

the synthesis of the evidence indicated the different strategies that can be adopted in the implementation process (introduction and optimization) of the Surgical Safety Checklist, and the facilitators and barriers that determine the success in using this tool.

Conclusion:

in health services, implementing the checklist is a complex and challenging process that requires effective leadership, clear delegation of responsibilities from each professional, collaboration between team members, and institutional support. The synthesis of the generated knowledge can assist nurses in decision making, especially in identifying strategies for the effective implementation of the Surgical Safety Checklist, since nursing has the potential to be a protagonist in the planning and implementation of best practices for patient safety.

Mobile persuasive technology for the teaching and learning in surgical safety: Content validation

BACKGROUND

Patient safety is a fundamental component of high-quality delivery of health care. However, despite scientific advances, surgical patients continue to face risks. Among the most common complications in surgery are operations on the wrong patient, performance of the wrong procedure or operation on the wrong surgical site, lack of adequate or required equipment, failure to prevent blood loss, and surgical items left inside patients. In this context, the planning and development of innovative educational strategies is important for prevention of adverse events and the improvement of surgical patient safety culture.

OBJECTIVE

To describe the process of validating the content of mobile technology for education about surgical safety.

METHODS

Content validation using the Delphi technique was carried out from December 2015 to January 2016 at a Federal University in South Brazil. Content development and animations were produced by the authors from a verification list for safety surgery and a safety surgery protocol. Twelve judges assessed five variables (Content, Language, Illustration, Layout and Motivation), for consensus on content validation. They evaluated quality of each item, using a rating scale consisting of five levels (1 to 5).

RESULTS

Two assessment rounds were done, with a mean content validity index (CVI) of 0.95 and 1.0 and a kappa index of >0.83 and >0.92, respectively. The judges provided positive comments about each phase of the study, most of comments highlights were: choice of very relevant subject matter, excellent quality of the material and the motivation that the material can provide to the target audience.

CONCLUSION

The study validated the content of learning technology by general consensus of judges with a high level of concordance among evaluated items. The application was considered adequate for educating students and health professionals about surgical safety.

Audit of compliance with WHO surgical safety checklist and building a shared mental model in the operating theatre

BACKGROUND

The use of the checklist has been shown to reduce patient death and postoperative complications and is mandated for use with all National Health Service (NHS) surgery. The aim was to obtain quantitative and qualitative data on compliance with WHO surgical safety checklist during operations in an NHS hospital.

METHOD

Data collection was by prospective observational audit of 34 operations using WHO checklist and 5 qualitative criteria to establish efficacy of use: (a) Staff stopped tasks to engage; (b) Staff attentive and listening; (c) Audible to all team; (d) Understanding was checked in briefs and questions/feedback asked; (e) All required staff present.Categorisation: grade 3 (all criteria), grade 2 (three to four of criteria), grade 1 (one to two of criteria). Checklist use was recorded by stage use (eg, Sign In) and component steps.

RESULTS

Checklist stages used were Brief (7/8), Sign In (32/34), Time Out (30/34), Sign Out (18/34) and Debrief (2/8). Checklist component steps were completed more fully in major versus minor operations (17.3/28 vs 8.4/28). Mean qualitative grade was greatest in major surgeries (2.2 vs 1.6) and using general anaesthesia (1.8 vs 1.3). 3/34 of operations achieved Grade 3.

CONCLUSION

Sign Out and Debrief compliance was low, as was full compliance with component steps of the WHO checklist, especially during minor operations. A focused checklist specific for minor operations could be introduced to remove unnecessary steps and mitigate against excessive omission. Improved qualitative use of the checklist is required to maximise effectiveness and facilitate a shared mental model.

World Health Organization Surgical Safety Checklist Modification: Do Changes Emphasize Communication and Teamwork?

BACKGROUND

The World Health Organization's (WHO) surgical safety checklist is meant to be customized to facilitate local implementation, encourage full-team participation, and promote a culture of safety. Although it has been globally adopted, little is known about the extent of checklist modification and the type of changes made.

METHODS

Nonsubspecialty surgical checklists were obtained through online search and targeted hospital requests. A detailed coding scheme was created to capture modifications to checklist content and formatting. Descriptive statistics were performed.

RESULTS

Of 155 checklists analyzed, all were modified. Compared with the WHO checklist, those in our sample contained more lines of text (median: 63 [interquartile range: 50-73] versus 56) and items (36 [interquartile range: 30-43] versus 28). A median of 13 new items were added. Items most frequently added included implants/special equipment (added by 84%), deep vein thrombosis prophylaxis/anticoagulation (added by 75%), and positioning (added by 63%). Checklists removed a median of 5 WHO items. The most frequently removed item was the pulse oximeter check (removed in 75%), followed by 4 items (each removed in 39%-48%) that comprise part of the WHO Checklist's "Anticipated Critical Events" section, which is intended for exchanging critical information. The surgeon was not explicitly mentioned in the checklist in 12%; the anesthesiologist/certified registered nurse anesthetist in 14%, the circulator in 10%, and the surgical tech/scrub in 79%.

CONCLUSIONS

Checklists are highly modified but often enlarged with items that may not prompt discussion or teamwork. Of concern is the frequent removal of items from the WHO's "Anticipated Critical Events" section.

Surgical Safety Checklists in Children's Surgery: Surgeons' Attitudes and Review of the Literature

Supplemental Digital Content is available in the text.

Introduction:

Surgical safety checklists (SSCs) aim to create a safe operating room environment for surgical patients. Provider attitudes toward checklists affect their ability to prevent harm. Pediatric surgeons’ perceptions surrounding SSCs, and their role in improving patient safety, are unknown.

Methods:

American Pediatric Surgical Association members conducted an online survey to evaluate the use of and attitudes toward SSCs. The survey measured surgeons’ perceptions of checklists, including the components that make them effective and barriers to participation. To better evaluate the available data on SSCs, the authors performed a systematic literature review on the use of SSCs with a focus on pediatric studies.

Results:

Of the 353 survey respondents, 93.6% use SSCs and 62.6% would want one used in their own child’s operation, but only 54.7% felt that checklists improve patient safety. Reasons for checklist skepticism included the length of the checklist process, a distraction from thoughtful patient care, and lack of data supporting use. Literature review shows that checklists improve communication, promote teamwork, and identify errors, but do not necessarily decrease morbidity. Staff perception is a major barrier to implementation.

Conclusions:

Almost all pediatric surgeons participate in SSCs at their institutions, but many question their benefit. Better pediatric surgeon engagement in checklist use is needed to change the safety culture, improve operating room communication, and prevent harm.

Administrator Perspectives on ICU-to-Ward Transfers and Content Contained in Existing Transfer Tools: a Cross-sectional Survey

BACKGROUND

The transfer of critically ill patients from the intensive care unit (ICU) to hospital ward is challenging. Shortcomings in the delivery of care for patients transferred from the ICU have been associated with higher healthcare costs and poor satisfaction with care. Little is known about how hospital ward providers, who accept care of these patients, perceive current transfer practices nor which aspects of transfer they perceive as needing improvement.

OBJECTIVE

To compare ICU and ward administrator perspectives regarding ICU-to-ward transfer practices and evaluate the content of transfer tools.

DESIGN

Cross-sectional survey design.

PARTICIPANTS

We administered a survey to 128 medical and/or surgical ICU and 256 ward administrators to obtain institutional perspectives on ICU transfer practices. We performed qualitative content analysis on ICU transfer tools received from respondents.

KEY RESULTS

In total, 108 (77%) ICU and 160 (63%) ward administrators responded to the survey. The ICU attending physician was reported to be "primarily responsible" for the safety (93% vs. 91%; p = 0.515) of patient transfers. ICU administrators more commonly perceived discharge summaries to be routinely included in patient transfers than ward administrators (81% vs. 60%; p = 0.006). Both groups identified information provided to patients/families, patient/family participation during transfer, and ICU-ward collaboration as opportunities for improvement. A minority of hospitals used ICU-to-ward transfer tools (11%) of which most (n = 21 unique) were designed to communicate patient information between providers (71%) and comprised six categories of information: demographics, patient clinical course, corrective aids, mobility at discharge, review of systems, and documentation of transfer procedures.

CONCLUSION

ICU and ward administrators have similar perspectives of transfer practices and identified patient/family engagement and communication as priorities for improvement. Key information categories exist.

"The Longest Way Round Is The Shortest Way Home": An Overhaul of Surgical Ward Rounds

Background

Ward rounds, a keystone of hospital surgical practice, have recently been under the spotlight. Poor-quality ward rounds can lead to a greater number of adverse events, thereby cascading to an increased financial strain on our already burdened healthcare systems. Faced with mounting pressures from both outside and inside health organizations, concerted efforts are required to restore it back into prominence where it can no longer take a backseat to the other duties of a surgeon.

Methods

The nucleus of this narrative review is derived from an extensive literature search on surgical ward rounds.

Results

In this review, we focus on the need for reforms, current characteristics of surgical ward rounds, obstacles encountered by competing interests and proposed solutions in delivery of effective ward rounds that can meet with newly laid guidelines.

Conclusion

Ward rounds should be standardized and prioritized to improve patient care.

Evaluating quality standards' adherence in surgical care: a case study from Pakistan

Objective

To explore the extent of adherence to surgical quality standards and areas of improvement.

Design

Multi-method case study was done. Assessment of observed/actual and self-reported adherence to quality standards in surgical care was done on WHO's safe-surgery checklist. Client satisfaction through exit interviews assessed of all operated during 1 month. Semi-structured interviews of key informants were conducted to identify areas of improvements in surgical care in this hospital.

Setting

Conducted in a tertiary care teaching hospital in Lahore, Pakistan.

Participants

Out of all 154 patients during 1 month were admitted with indications for surgery and 35.71% patients gave consent and participated in the study.

Outcome measure

Actual and reported adherence data were categorized in excellent, good, satisfactory and poor adherence to standards. For in-depth interviews, themes were identified from textual data.

Results

Overall activities in surgical department were performed well, patients were satisfied and hospital surgical mortality rate was zero but infection control measures needs attention and these practices were found poor with high re-operation and re-admissionrate (P-value < 0.001). Adherence to standards of surgical quality was inadequate in pre-operative, operative and post-op steps as assessed on the checklist but actual adherence was different from reported adherence by surgical care providers.

Conclusion

This case study shows a complete picture of surgical care quality in a hospital of Pakistan. Discrepancy between perceived/reported adherence and actual practice was found. Patients' satisfaction is not a reliable outcome measure of surgical care quality.

Surgical quality indicators in low-resource settings: A new evidence-based tool

BACKGROUND

Worldwide efforts to improve access to surgical care must be accompanied by improvements in the quality of surgical care; however, these efforts are contingent on the ability to measure quality. This report describes a novel, evidence-based tool to measure quality of surgical care in low-resource settings.

METHODS

We defined a widely applicable, multidimensional conceptual framework for quality. The suitability of currently available quality metrics to low-resource settings was evaluated. Then we developed new indicators with sufficient supportive evidence to complete the framework. The complete set of metrics was condensed into four collection sources and tools.

RESULTS

The following 15 final evidence-based indicators were defined: (1) Safe structure: morbidity and mortality conference; (2) safe process: use of the safe surgery checklist; (3) (4) safe outcomes: perioperative mortality rate and proportion of cases with complications graded >2 on the Clavien-Dindo scale; (5) effective structure: provider density; (6) effective process: procedure rate; (7) effective outcome: rate of caesarean sections; (8) patient-centered process: use of informed consent; (9) patient-centered outcome: patient hospital satisfaction questionnaire; (10) timely structure: travel time to hospital; (11) timely process: time from emergency department presentation to non-elective abdominal surgery; (12) timely outcome: patient follow-up plan; (13) efficient process: daily operating room usage; (14) equitable outcome: comparative income of patients compared with population; and (15) proportion of patients facing catastrophic expenditure because of surgical care.

CONCLUSION

This tool provides an evidence-based conceptual tool to assess the quality of surgical care in diverse low-resource settings.