Effect of a comprehensive surgical safety system on patient outcomes

Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures

BACKGROUND

Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries.

METHODS

From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability.

RESULTS

Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses.

CONCLUSIONS

Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

Effectiveness and meaningful use of paediatric surgical safety checklists and their implementation strategies: a systematic review with narrative synthesis

OBJECTIVE

To examine the effectiveness and meaningful use of paediatric surgical safety checklists (SSCs) and their implementation strategies through a systematic review with narrative synthesis.

SUMMARY BACKGROUND DATA

Since the launch of the WHO SSC, checklists have been integrated into surgical systems worldwide. Information is sparse on how SSCs have been integrated into the paediatric surgical environment.

METHODS

A broad search strategy was created using Pubmed, Embase, CINAHL, Cochrane Central, Web of Science, Science Citation Index and Conference Proceedings Citation Index. Abstracts and full texts were screened independently, in duplicate for inclusion. Extracted study characteristic and outcomes generated themes explored through subgroup analyses and idea webbing.

RESULTS

1826 of 1921 studies were excluded after title and abstract review (kappa 0.77) and 47 after full-text review (kappa 0.86). 20 studies were of sufficient quality for narrative synthesis. Clinical outcomes were not affected by SSC introduction in studies without implementation strategies. A comprehensive SSC implementation strategy in developing countries demonstrated improved outcomes in high-risk surgeries. Narrative synthesis suggests that meaningful compliance is inconsistently measured and rarely achieved. Strategies involving feedback improved compliance. Stakeholder-developed implementation strategies, including team-based education, achieved greater acceptance. Three studies suggest that parental involvement in the SSC is valued by parents, nurses and physicians and may improve patient safety.

CONCLUSIONS

A SSC implementation strategy focused on paediatric patients and their families can achieve high acceptability and good compliance. SSCs' role in improving measures of paediatric surgical outcome is not well established, but they may be effective when used within a comprehensive implementation strategy especially for high-risk patients in low-resource settings.

Incidence of Wrong-Site Surgery List Errors for a 2-Year Period in a Single National Health Service Board

Introduction

Wrong-site/side surgical “never events” continue to cause considerable harm to patients, healthcare professionals, and organizations within the United Kingdom. Incidence has remained static despite the mandatory introduction of surgical checklists. Operating theater list errors have been identified as a regular contributor to these never events. The aims of the study were to identify and to learn from the incidence of wrong-site/side list errors in a single National Health Service board.

Methods

The study was conducted in a single National Health Service board serving a population of approximately 300,000. All theater teams systematically recorded errors identified at the morning theater brief or checklist pause as part of a board-wide quality improvement project. Data were reviewed for a 2-year period from May 2013 to April 2015, and all episodes of wrong-site/side list errors were identified for analysis.

Results

No episodes of wrong-site/side surgery were recorded for the study period. A total of 86 wrong-site/side list errors were identified in 29,480 cases (0.29%). There was considerable variation in incidence between surgical specialties with ophthalmology recording the largest proportion of errors per number of surgical cases performed (1 in 87 cases) and gynecology recording the smallest proportion (1 in 2671 cases). The commonest errors to occur were “wrong-side” list errors (62/86, 72.1%).

Discussion

This is the first study to identify incidence of wrong-site/site list errors in the United Kingdom. Reducing list errors should form part of a wider risk reduction strategy to reduce wrong-site/side never events. Human factors barrier management analysis may help identify the most effective checks and controls to reduce list errors incidence, whereas resilience engineering approaches should help develop understanding of how to best capture and neutralize errors.

WHO Safer Surgery checklist compliance amongst paediatric emergency plastic surgery patients in an UK hospital

Introduction

The WHO Safer Surgery checklist has become an important component of perioperative safety. Our objective, was to determine the compliance of completing the checklist for paediatric emergency plastic surgery patients at our unit.

Methods

An initial baseline was performed with 70 patients over two months at our unit. Following this, we raised awareness at an audit meeting and closed the audit loop using 80 patients over two months. The audit is reported in line with SQUIRE 2.0 criteria.

Results

Initial compliance was 88% overall and this increased to 91% post-intervention. Compliance with the individual stages in both cycles was for sign-in: 85%–86%, for time-out 92%–98% and for sign-out 86%–89%. Around one in four checklists were not scanned in both periods.

Conclusion

This audit showed a high overall level of compliance in the checklists that were scanned and available for scrutiny. We have identified the areas that most need improvement and suggest ways for doing so.

•

This study has shown the value of raising awareness of the WHO checklist for optimizing perioperative safety.

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An overall increase in checklist compliance from 88% to 91% was found.

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We have identified the areas that most need improvement and suggest ways for doing so.

Operating Room Crisis Checklists and Emergency Manuals

Crisis checklists and emergency manuals are cognitive aids that help team performance and adherence to evidence-based practices during operating room crises. Resources to enable local implementation and training (key for effective use) are linked at http://www.emergencymanuals.org.

Supplemental Digital Content is available in the text.

The Impact of Checklists on Inpatient Safety Outcomes: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Systematic reviews of non-randomized controlled trials (RCTs) suggest that using a checklist results in fewer medical errors and adverse events, but these evaluations are at risk of bias.

OBJECTIVE

To conduct a systematic review of RCTs of checklists to determine their effectiveness in improving patient safety outcomes in hospitalized patients.

METHODS

Ovid EMBASE, Ovid MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials were searched from inception until December 8, 2016. The search was restricted to RCTs. Included studies reported patient safety outcomes of a checklist intervention. Data extracted included the study characteristics, setting, population, intervention, outcomes measures, and sample size.

MEASUREMENTS AND MAIN RESULTS

11,225 citations were identified, of which 9 (16,987 patients) satisfied the inclusion criteria. Citations reported evaluations of checklists designed to improve surgical safety, prescription of medications, heart failure management, pain control, infection control precautions, and physician handover. Studies reported significant reductions in postoperative complications and medication-related problems and improved compliance with evidence-based prescribing of medications, infection control precautions, and patient handover procedures. 30-day mortality was reported in 3 studies and was significantly lower among patients allocated to the checklist group (odds ratio 0.60, 95% confidence interval, 0.41-0.89, 𝑃 = 0.01, I² = 0.0%, 𝑃 = 0.573). Methodological quality of the studies was moderate.

CONCLUSION

A small number of citations report RCT evaluations of the impact of checklists on patient safety. There is an urgent need for high-quality evaluations of the effectiveness of patient safety checklists in inpatient healthcare settings to substantiate their perceived benefits.

Implementation Science: A Neglected Opportunity to Accelerate Improvements in the Safety and Quality of Surgical Care

OBJECTIVE

The aim of this review was to emphasize the importance of implementation science in understanding why efforts to integrate evidence-based interventions into surgical practice frequently fail to replicate the improvements reported in early research studies.

SUMMARY OF BACKGROUND DATA

Over the past 2 decades, numerous patient safety initiatives have been developed to improve the quality and safety of surgical care. The surgical community is now faced with translating "promising" initiatives from the research environment into clinical practice-the World Health Organization (WHO) has described this task as one of the greatest challenges facing the global health community and has identified the importance of implementation science in scaling up evidence-based interventions.

METHODS

Using the WHO surgical safety checklist, a prominent example of a rapidly and widely implemented surgical safety intervention of the past decade, a review of literature, spanning surgery, and implementation science, was conducted to identify and describe a broad range of factors affecting implementation success, including contextual factors, implementation strategies, and implementation outcomes.

RESULTS

Our current approach to conceptualizing and measuring the "effectiveness" of interventions has resulted in factors critical to implementing surgical safety interventions successfully being neglected.

CONCLUSION

Improvements in the safety and quality of surgical care can be accelerated by drawing more heavily upon implementation science and that until this rapidly evolving field becomes more firmly embedded into surgical research and implementation efforts, our understanding of why interventions such as the checklist "work" in some settings and appear "not to work" in other settings will be limited.

A qualitative study of patient and provider experiences during preoperative care transitions

AIMS AND OBJECTIVES

To explore the issues and challenges of care transitions in the preoperative environment.

BACKGROUND

Ineffective transitions play a role in a majority of serious medical errors. There is a paucity of research related to the preoperative arena and the multiple inherent transitions in care that occur there.

DESIGN

Qualitative descriptive design was used.

METHODS

Semistructured interviews were conducted in a 975-bed academic medical centre.

RESULTS

A total of 30 providers and 10 preoperative patients participated. Themes that arose were as follows: (1) need for clarity of purpose of preoperative care, (2) care coordination, (3) interprofessional boundaries of care and (4) inadequate time and resources.

CONCLUSION

Effective transitions in the preoperative environment require that providers bridge scope of practice barriers to promote good teamwork. Preoperative care that is a product of well-informed providers and patients can improve the entire perioperative care process and potentially influence postoperative patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Nurses are well positioned to bridge the gaps within transitions of care and accordingly affect health outcomes.

Litigation in thyroid surgery in England

Thyroid surgery has the potential for significant life-changing postoperative complications. Since 1995, the NHS Litigation Authority has handled litigation claims in England. This article reviews all thyroid surgery litigation claims between 1995 and 2012 and looks at potential strategies to minimize future claims.

Protocol for a multicentre, multistage, prospective study in China using system-based approaches for consistent improvement in surgical safety

INTRODUCTION

Surgical safety has emerged as a crucial global health issue in the past two decades. Although several safety-enhancing tools are available, the pace of large-scale improvement remains slow, especially in developing countries such as China. The present project (Modern Surgery and Anesthesia Safety Management System Construction and Promotion) aims to develop and validate system-based integrated approaches for reducing perioperative deaths and complications using a multicentre, multistage design.

METHODS AND ANALYSIS

The project involves collection of clinical and outcome information for 1 20 000 surgical inpatients at four regionally representative academic/teaching general hospitals in China during three sequential stages: preparation and development, effectiveness validation and improvement of implementation for promotion. These big data will provide the evidence base for the formulation, validation and improvement processes of a system-based stratified safety intervention package covering the entire surgical pathway. Attention will be directed to managing inherent patient risks and regulating medical safety behaviour. Information technology will facilitate data collection and intervention implementation, provide supervision mechanisms and guarantee transfer of key patient safety messages between departments and personnel. Changes in rates of deaths, surgical complications during hospitalisation, length of stay, system adoption and implementation rates will be analysed to evaluate effectiveness and efficiency.

ETHICS AND DISSEMINATION

This study was approved by the institutional review boards of Peking Union Medical College Hospital, First Hospital of China Medical University, Qinghai Provincial People's Hospital, Xiangya Hospital Central South University and the Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences. Study findings will be disseminated via peer-reviewed journals, conference presentations and patent papers.

Time-Out and Checklists: A Survey of Rural and Urban Operating Room Personnel

Surgical safety checklists were introduced to improve patient safety. Urban and rural hospitals are influenced by differing factors, but how these factors affect patient care is unknown. This study examined time-out and checklist processes in rural and urban operating rooms and found that although checklist use has been adopted in many organizations, use is inconsistent across both settings. An understanding of these variations is needed to improve utilization.

A retrospective cohort study of adverse events in patients undergoing orthopaedic surgery

Background

This study’s objective was to identify adverse events following common orthopaedic procedures, and to estimate the incidence rates and risks of these events and their associations with age, sex, and comorbidities.

Methods

This retrospective cohort study manually reviewed and extracted electronic medical data on the incidence and predictors of adverse events that occurred within 90 days of the 50 most frequent orthopaedic surgeries at an academic hospital in 2010. We also extracted demographic data, baseline comorbidities, and duration of follow-up (≤90 days). Patients were scored on the Charlson Comorbidity Index (CCI) and the Functional Comorbidity Index (FCI). We estimated incidence rates and risks for all events and associations using regression methods. Prolonged pain 42-days post-surgery was treated as a separate outcome.

Results

We included 1,552 patients; average age was 53.4 years, and 51.7% were female. A total of 1,148 adverse events were identified in 729 patients. The incidence rate of all adverse events was 10 events per 1,000 person-days at risk; 47% of all patients experienced at least one adverse event within 90 days. The most frequent events were prolonged pain (31% of all adverse events) and persistent swelling (7%). We found positive associations between both comorbidity scores and the incidence rate and 90-day risk of all adverse events, excluding pain, adjusting for age and sex (neither of which was associated with adverse events); the association was stronger for the FCI than for the CCI. For total hip arthroplasty (THA) and total knee arthroplasty (TKA), the incidence rate of all adverse events, excluding pain, was positively associated with both comorbidity scores and age; the 90-day risk was positively associate with the FCI score and male sex. The prevalence of prolonged pain at 42 days was greater in patients with higher FCI scores; for THA and TKA only, pain prevalence was greater in those with higher FCI scores and in men.

Conclusions

Adverse events are frequent following common orthopaedic procedures. The incidence is greatest for patients with more functional comorbidities. For THA and TKA procedures, being male and being older are also associated with a greater incidence of adverse events.

Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative

Background

‘Failure to rescue’ of hospitalized patients with deteriorating physiology on general wards is caused by a complex array of organisational, technical and cultural failures including a lack of standardized team and individual expected responses and actions. The aim of this study using a learning collaborative method was to develop consensus recomendations on the utility and effectiveness of checklists as training and operational tools to assist in improving the skills of general ward staff on the effective rescue of patients with abnormal physiology.

Methods

A scoping study of the literature was followed by a multi-institutional and multi-disciplinary international learning collaborative. We sought to achieve a consensus on procedures and clinical simulation technology to determine the requirements, develop and test a safe using a checklist template that is rapidly accessible to assist in emergency management of common events for general ward use.

Results

Safety considerations about deteriorating patients were agreed upon and summarized. A consensus was achieved among an international group of experts on currently available checklist formats performing poorly in simulation testing as first responders in general ward clinical crises. The Crisis Checklist Collaborative ratified a consensus template for a general ward checklist that provides a list of issues for first responders to address (i.e. ‘Check In’), a list of prompts regarding common omissions (i.e. ‘Stop & Think’), and, a list of items required for the safe “handover” of patients that remain on the general ward (i.e. ‘Check Out’). Simulation usability assessment of the template demonstrated feasibility for clinical management of deteriorating patients.

Conclusions

Emergency checklists custom-designed for general ward patients have the potential to guide the treatment speed and reliability of responses for emergency management of patients with abnormal physiology while minimizing the risk of adverse events. Interventional trials are needed.

Quality Improvement and Reporting Systems: What the Oral and Maxillofacial Surgeon Should Know

Health care is an inherently dangerous environment, and patient safety should be an explicit goal of oral and maxillofacial surgery. Important components of a safety program include a nonpunitive safety culture, the implementation of patient safety practices, standardized incident reporting and adverse event analysis, regular self-assessment, and internal and external benchmarking. Implementation of a safety program requires the strong commitment of leadership and the engagement and empowerment of all employees. Oral and maxillofacial surgery can become the model dental specialty by implementing patient safety programs for office-based surgery. The programs could then be used by all dental practitioners performing oral surgery in the office.

The Association of Shelter Veterinarians' 2016 Veterinary Medical Care Guidelines for Spay-Neuter Programs

As community efforts to reduce the overpopulation and euthanasia of unwanted and unowned cats and dogs have increased, many veterinarians have increasingly focused their clinical efforts on the provision of spay-neuter services. Because of the wide range of geographic and demographic needs, a wide variety of spay-neuter programs have been developed to increase delivery of services to targeted populations of animals, including stationary and mobile clinics, MASH-style operations, shelter services, community cat programs, and services provided through private practitioners. In an effort to promote consistent, high-quality care across the broad range of these programs, the Association of Shelter Veterinarians convened a task force of veterinarians to develop veterinary medical care guidelines for spay-neuter programs. These guidelines consist of recommendations for general patient care and clinical procedures, preoperative care, anesthetic management, surgical procedures, postoperative care, and operations management. They were based on current principles of anesthesiology, critical care medicine, infection control, and surgical practice, as determined from published evidence and expert opinion. They represent acceptable practices that are attainable in spay-neuter programs regardless of location, facility, or type of program. The Association of Shelter Veterinarians envisions that these guidelines will be used by the profession to maintain consistent veterinary medical care in all settings where spay-neuter services are provided and to promote these services as a means of reducing sheltering and euthanasia of cats and dogs.

Safety Culture in Neonatal Intensive Care Units in the Gaza Strip, Palestine: A Need for Policy Change

INTRODUCTION

Assessment of the prevailing safety culture within the Gazan health care system can be used to identify problem areas. Specifically, the need for improvements, raising awareness about patient safety, the identification and evaluation of existing safety programs and interventions for improving the safety culture. This study aims to assess the safety culture in the neonatal intensive care units (NICUs) in Gaza Strip hospitals and to assess the safety culture in regards to caregivers' characteristics.

METHODS

In a cross-sectional study using a census sample, we surveyed all nurses and physicians working in at all the NICUs in the Gaza Strip, Palestine. The Safety Attitudes Questionnaire (SAQ) which includes six scales was used to assess participants' attitudes towards safety culture.

RESULTS

The overall score for SAQ was 63.9. Domains' scores ranged between 55.5 (perception of management) and 71.8 (stress recognition). The scores reported by our participants fell below the 75 out of a possible score of 100, which was considered as a cut-off point for a positive score. Moreover, our results revealed substantial variation in safety culture domain scores among participating NICUs.

CONCLUSION

These results should be an indicator to our health care policy makers to modify current or adopt new health care policies to improve safety culture. It should also be a call to design customized programs for improving the safety culture in NICUs in the Gaza Strip.

Recommendations for surgical safety checklist use in Canadian children's hospitals

BACKGROUND

There is ample evidence that avoidable harm occurs in patients, including children, who undergo surgical procedures. Among a number of harm mitigation strategies, the use of surgical safety checklists (SSC) is now a required organizational practice for accreditation in all North American hospitals. Although much has been written about the effects of SSC on outcomes of adult surgical patients, there is a paucity of literature on the use and role of the SSC as an enabler of safe surgery for children.

METHODS

The Pediatric Surgical Chiefs of Canada (PSCC) advocates on behalf of all Canadian children undergoing surgical procedures. We undertook a survey of the use of SSC in Canadian children's hospitals to understand the variability of implementation of the SSC and understand its role as both a measure and driver of patient safety and to make specific recommendations (based on survey results and evidence) for standardized use of the SSC in Canadian children's hospitals.

RESULTS

Survey responses were received from all 15 children's hospitals and demonstrated significant variability in how the checklist is executed, how compliance is measured and reported, and whether or not use of the checklist resulted in specific instances of error prevention over a 12-month observation period. There was near unanimous agreement that use of the SSC contributed positively to the safety culture of the operating room.

CONCLUSION

Based on the survey results, the PSCC have made 5 recommendations regarding the use of the SSC in Canadian children's hospitals.

Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial

OBJECTIVES

Quality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay.

METHODS

An antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol.

RESULTS

Between 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6-11.5) versus intervention 10.1 days (95% CI 8.9-11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0-3.0), p<0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance.

CONCLUSIONS

Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist.

Human Error in Throat Pack Management: Report of Two Cases

Throat packs are frequently used after tracheal intubation during ear, nose, and throat surgery. We report 2 cases of complications related to throat packs retained at the end of surgery. Miscommunication between anesthesiology and surgery teams on throat pack management led to an upper gastrointestinal endoscopy examination under general anesthesia in the first case and to severe respiratory distress requiring tracheal reintubation in the second case. Our 2 case reports highlight the importance of good communication between anesthesiology and surgery teams and of standardized procedures and checklists for the management of throat packs to ensure patient safety.

Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Quality Improvement Collaborative

BACKGROUND

The 2015 American Academy of Pediatrics Neonatal Resuscitation Program (NRP) and International Liaison Committee on Resuscitation (ILCOR) resuscitation guidelines state, "It is still suggested that briefing and debriefing techniques be used whenever possible for neonatal resuscitation." Effective communication and reliable delivery of evidence-based best practices are critical aspects of the 2015 NRP guidelines. To promote optimal communication and best practice-focused checklists use during active neonatal resuscitation, the Readiness Bundle (RB) was integrated within the larger change package deployed in the California Perinatal Quality Care Collaborative's (CPQCC) 12-month Delivery Room Management Quality Improvement Collaborative.

METHODS

The RB consisted of (1) a checklist for high-risk neonatal resuscitations and (2) briefings and debriefings to improve teamwork and communication in the delivery room (DR). Implementation of the RB was encouraged, compliance with the RB was tracked monthly up through 6 months after the completion of the collaborative, and satisfaction with the RB was evaluated.

RESULTS

Twenty-four neonatal intensive care units (NICUs) participated in the CPQCCDR collaborative. Before the initiation of the collaborative, the elements of the RB were complied with in 0 of 740 reported deliveries (0%). During the 12-month collaborative, compliance with the RB improved to a median of 71%, which was surpassed in the 6-month period after the collaborative ended (80%). One-hundred percent of responding NICUs would recommend the RB to other NICUs working on improving DR management.

CONCLUSIONS

The RB was rapidly adopted, with compliance sustained for 6 months after completion of the collaborative. Inclusion of the RB in the next generation of the NRP guidelines is encouraged.

Perioperative Safety in Plastic Surgery: Is the World Health Organization Checklist Useful in a Broad Practice?

INTRODUCTION

In October 2007, the World Health Organization (WHO) introduced the Safe Surgery Saves Lives Program, the cornerstone of which was a 19-item safe-surgery checklist (SSC), in 8 selected hospitals around the world. After implementation, death rates decreased significantly from 1.5% to 0.8% (P = 0.003), inpatient complications reduced from 11% to 7% (P < 0.001), as did rates of surgical site infection (P < 0.001) and wrong-sided surgery (P < 0.47), across all sites. On the basis of these impressive reductions in complications and mortality, our institution adopted the WHO SSC in April 2009, with a few additional measures included, such as assuring presence of appropriate implants and administration of preoperative antibiotics and thromboembolic prophylaxis. Our purpose was to evaluate the efficacy and applicability of the surgical safety checklist in a multisurgeon plastic surgery hospital-based practice, by analyzing its effect on morbidity and outcomes.

METHODS

A retrospective review of the morbidity and mortality data from the Department of Plastic Surgery at Loma Linda University Medical Center was conducted from January 2006 to July 2012. Data on morbidity and mortality before and after implementation of the surgical safety checklist were analyzed.

RESULTS

The most common complications were wound related, including infection, seroma and/or hematoma, dehiscence, and flap-related complications. No significant decrease in the measured complications, neither total nor each specific complication, occurred after the implementation of the SSC. Although verifying appropriate administration of antibiotic, presence of appropriate equipment and materials, performing a preoperative formal pause, and verifying the execution of the other measures included in the SSC is critical, untoward outcomes after implementation of the checklist did not measurably decrease. In its current form as this time, the checklist does not seem to be efficacious in Plastic Surgery.

CONCLUSIONS

Although certain elements of the WHO SSC checklist are universal and should be adopted, certain specific aspects require modification to improve applicability in a plastic surgery-specific practice. This necessitates the creation of a surgical safety checklist specifically for plastic surgery as other surgical specialties have proposed.

An analysis of perioperative adverse neurological events associated with anesthetic management at a Tertiary Care Center of a developing country

BACKGROUND AND AIMS

Existing literature on neurological complications related to anesthesia is reported from affluent countries but the trends may vary in less affluent countries.

MATERIAL AND METHODS

The objective was to find the associated factors contributing to neurological adverse events occurring within 48 h of anesthesia and surgery. The existing departmental morbidity and mortality database was reviewed from 1992 to 2012 for major adverse neurological events. A standardized methodology was used in reviewing and classifying the data. All adverse events were predefined and categorized before filling the form into the following headers; meningitis, cord/plexus/peripheral nerve injury, stroke, paraparesis/paraplegia/quadriparesis/or quadriplegia, new onset postoperative seizures, postoperative vocal cord injury, and a miscellaneous group.

RESULTS

During this period, 195,031 patients underwent anesthesia and twenty-nine patients had major neurological morbidity within 48 h (1:6700). There were three cases of meningitis/meningism, eight cases of cord, plexus or peripheral nerve injury, seven of stroke, four had new onset seizures, one had quadriparesis, five had vocal cord, and one had cranial nerve palsy. Forty-one percent cases received regional anesthesia alone or in combination with the general. In six cases, anesthesia was considered solely responsible. Human error contributed to 93% of these events.

CONCLUSION

This data has helped in identifying areas of concern and can serve as a reference for further audits in the region.

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings

Handoffs represent a critical transition point in patient care that play a key role in patient safety. Our quality improvement project was a descriptive observational study aimed at standardizing pediatric hospitalist handoffs via implementation of a handoff checklist, with the goal of improving handoff quality and physician satisfaction within six months. The handoff checklist was quickly adapted by hospitalists, with median compliance rate of 83% during the study. Handoff quality was assessed by trained observers using the validated Handoff Clinical Evaluation Exercise (CEX) tool at multiple time periods pre- and post-implementation (at 2, 6, 12, and 24 months). Handoff quality improved during our study, with a significant decrease in the percentage of "unsatisfactory" handoffs from 9% to 0% (p-value 0.004), an effect which was sustained after initial project completion. The cumulative time required for verbal handoffs for different attending physicians paralleled patient census. However, our project identified wasted down time between individual physician handoffs, and an intervention to change shift times led to a decrease in the average total handoff process time from 86 minutes to 60 minutes, p-value <0.001. An average of 7.4 patient care items was identified during handoffs. A physician perception survey revealed improved situational awareness, efficiency, patient safety, and physician satisfaction as a result of our handoff improvement project. In conclusion, implementation of a checklist and standardized handoff process for pediatric hospitalists improved handoff efficiency and quality, as well as physician satisfaction.

Implementation of the surgical safety checklist at a tertiary academic center: Impact on safety culture and patient outcomes

BACKGROUND

The impact and efficacy of the World Health Organization Surgery Safety Checklist (SSC) is uncertain. We sought to determine if the SSC decreases complications and examined the attitudes of the surgical team members following implementation of the SSC.

METHODS

A 28-question survey was developed to assess perspectives of surgical team members at the University of Vermont Medical Center (UVMC). The University Health System Consortium database was examined to compare the rates of nine complications before and after SSC implementation using Chi square analysis and Fisher's exact test.

RESULTS

There was no significant decrease in any of the nine complications 2 years after SSC implementation. There was overall agreement that the SSC improved communication, safety, and prevented errors in the operating room. However, there was disagreement between nursing and surgeons over whether all three parts of the SSC were always completed.

CONCLUSIONS

Implementation of the SSC did not result in a significant decrease in perioperative morbidity or mortality. However, it did improve the perception of safety culture by operating room staff.

A multifaceted intervention to reduce drug-related complications in surgical patients

AIM

The P-REVIEW study was a prospective, multicenter, open intervention study, designed to determine whether a multifaceted intervention of educating the prescriber combined with medication review and pharmaceutical visits to the ward by the hospital pharmacist could lead to a reduction in drug-related complications among surgical patients.

METHODS

A total of 6780 admissions of 5940 patients to surgical, urological and orthopaedic wards during the usual care period and 6484 admissions of 5711 patients during the intervention period were included. An educational programme covering pain management, antithrombotics, fluid and electrolyte management, prescription in case of renal insufficiency and antibiotics was developed. National and local hospital guidelines were included. Hospital pharmacists performed medication safety consultations, combining medication review of high-risk patients and a visit to the physician on the ward.

RESULTS

A significantly lower proportion of admissions with one or more clinically relevant, potentially preventable, drug-related problems (including death, temporary or sustained disability, increased length of hospital stay or readmission within 30 days) occurred in the intervention period (1.1% (73/6484) compared to the usual care period [1.6% (106/6780)] (P = 0.029). The relative risk (RR) was 0.72 (95% CI 0.53-0.97). Several types of drug-related problems occurred less frequently. Costs incurred as result of time spent on study-related activities were not different before and after the intervention.

CONCLUSIONS

The P-REVIEW study shows that education and support of the prescribing physician with respect to high-risk patients in surgical departments leads to a significant, clinically relevant benefit for patients without generating additional costs.

Impact of Checklist Use on Wellness and Post-Elective Surgery Appointments in a Veterinary Teaching Hospital

Cognitive functioning is often compromised with increasing levels of stress and fatigue, both of which are often experienced by veterinarians. Many high-stress fields have implemented checklists to reduce human error. The use of these checklists has been shown to improve the quality of medical care, including adherence to evidence-based best practices and improvement of patient safety. Although it has been recognized that veterinary medicine would likely demonstrate similar benefits, there have been no published studies to date evaluating the use of checklists for improving quality of care in veterinary medicine. The purpose of the current study was to evaluate the impact of checklists during wellness and post-elective surgery appointments conducted by fourth-year veterinary students within their Community Practice rotation at a US veterinary teaching hospital. Students were randomly assigned to one of two groups: those who were specifically asked to use the provided checklists during appointments, and those who were not asked to use the checklists but had them available. Two individuals blinded to the study reviewed the tapes of all appointments in each study group to determine the amount and type of medical information offered by veterinary students. Students who were specifically asked to use the checklists provided significantly more information to owners, with the exception of keeping the incision clean. Results indicate the use of checklists helps students provide more complete information to their clients, thereby potentially enhancing animal care.

Challenging the knowledge base and skillset for providing surgical consent by orthopedic and plastic surgeons in the Netherlands: an identified area of improvement in patient safety

Background

Successfully completing a surgical informed consent process is an important element of the preoperative consult. A previous study of Dutch general surgeons demonstrated that the implementation of SIC did not meet acceptable standards. However, the quality of the SIC process in the orthopedic surgical or plastic surgical arena is unknown.

Methods

Following ethical approval, an online survey investigating specifics of surgical informed consent was performed among members of the Dutch Scientific Association of Orthopedic Surgeons and the Dutch Society for Plastic Surgery.

Results

A total of 335 responses from a majority of departments of orthopedic (86 %) and plastic surgery (78 %) were eligible for analysis. Scores on knowledge were poor as only 50 % recognized the three basic elements of surgical informed consent (competence, exchange of information and consent). The orthopedic group used more tools in the surgical informed consent process, such as instruction movies and websites or specialized nursing staff, compared to plastic surgery (orthopedic: 31-50 % vs. plastic: 6-30 %, p = 0.05- < 0.001). In contrast, surgical informed consent forms were used more frequently by the plastic surgical group (orthopedic 21 % vs. plastic:42 % p < 0.001). Control of the efficacy of the surgical informed consent process was low, 36 % in both groups. One in every seven orthopedic or plastic surgeons was faced with an official surgical informed consent-related complaint in the previous five years.

Conclusions

Similar to general surgeons, Dutch orthopedic and plastic surgeons demonstrate poor knowledge and skills regarding surgical informed consent. Increased awareness, better training and use of modern tools including standard forms and online software programs will improve the SIC process and will optimize patient care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13037-016-0110-0) contains supplementary material, which is available to authorized users.

Operating Room Clinicians' Attitudes and Perceptions of a Pediatric Surgical Safety Checklist at 1 Institution

BACKGROUND

Despite mounting evidence that use of surgical checklists improves patient morbidity and mortality, compliance among surgical teams in executing required elements of checklists has been low. Recognizing that clinicians' receptivity is a major determinant of checklist use, we conducted a survey to investigate how mandated use of a surgical checklist impacts its operating room clinicians' attitudes about and perceptions of operating room safety, efficiency, teamwork, and prevention of medical errors.

METHODS

Operating room clinicians at 1 pediatric hospital were surveyed on their attitudes and perception of the novel Pediatric Surgical Safety Checklist and the impact the checklist had on efficiency, teamwork, and prevention of medical errors 1 year after its implementation. The survey responses were compared and classified by multidisciplinary perioperative clinical staff.

RESULTS

Most responses reflected positive attitudes toward checklist use. The respondents felt that the checklist reduced complications and errors and improved patient safety, communication among team members, teamwork in complex procedures, and efficiency in the operating room. Many operating room staff also reported that checklist use had prevented or averted an error or a complication. Perceptions varied according to perioperative clinical discipline, reflecting differences in perspectives. For example, the nurses perceived a higher rate of consent-related errors and site marking errors than did the physicians; the surgeons reported more antibiotic timing and equipment errors than did others.

CONCLUSIONS

The surgical staff at 1 pediatric hospital who responded viewed the novel Pediatric Surgical Safety Checklist as potentially beneficial to operative patient safety by improving teamwork and communication, reducing errors, and improving efficiency. Responses varied by discipline, indicating that team members view the checklist from different perspectives.

Compliance and Effectiveness of WHO Surgical Safety Check list: A JPMC Audit

Objective:

To assess World Health Organization (WHO) Surgical Safety Checklist (SSC), compliance and its effectiveness in reducing complications and final outcome of patients.

Methods:

This was a prospective study done in Department of General Surgery (Ward 02), Jinnah Postgraduate Medical Centre (JPMC), Karachi. The study included Total 3638 patients who underwent surgical procedure in elective theatre in four years from November 2011 to October 2015 since the SSC was included as part of history sheets in ward. Files were checked to confirm the compliance with regards to filling the three stage checklist properly and complications were noted.

Results:

In 1st year, out of 840 surgical procedures, SSC was properly marked in 172 (20.4%) cases. In 2nd year, out of 857 surgical procedures 303 (35.3%) cases were marked which increased in 3rd year out of 935 surgical procedures 757 (80.9%) cases and in 4th year out of 932 surgical procedures 838 (89.9%) cases were marked. No significant change in site and side (left or right) complications were noted in all four years. Surgical Site Infection (SSI) was noted in 59 (7.50%), 52 (6.47%), 44 (4.70%) and 20 (2.12%) cases in 1st, 2nd, 3rd and 4th year respectively. SSI in laparoscopic cholecystectomies was 41 (20.8 %), 45 (13%), 20 (5.68%) and 4 (1.12%) in 1st, 2nd, 3rd and 4th year respectively. No significant change in chest complications were noted in all four years. Mortality rate also remained same in all four years.

Conclusion:

WHO SSC is an effective tool in reducing in-hospital complications thus producing a favorable outcome. Realization its efficacy would improve compliance.

Cluster randomized trial to evaluate the impact of team training on surgical outcomes

Background

The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation.

Methods

A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals.

Results

Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P &lt; 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P &lt; 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals.

Conclusion

Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

Process Improvement in Thoracic Donor Organ Procurement: Implementation of a Donor Assessment Checklist

BACKGROUND

Donor organs are often procured by junior staff in stressful, unfamiliar environments where a single adverse event can be catastrophic. A formalized checklist focused on preprocedural processes related to thoracic donor organ procurement could improve detection and prevention of near miss events.

METHODS

A checklist was developed centered on patient identifiers, organ compatibility and quality, and team readiness. It went through five cycles of feedback and revision using a panel of expert procurement surgeons. Educational in-service sessions were held on the use of the checklist as well as best organ assessment practices. Near miss events before the survey were tallied by retrospective review of 20 procurements, and near misses after checklist implementation were prospectively recorded. We implemented the checklist for 40 donor lung and heart procurements: 20 from Cleveland Clinic and 20 from the University of Minnesota. A final survey assessment was used to determine ease of use.

RESULTS

Nine near miss events were reported in 20 procurements before use of the checklist. Thirty-one near miss events of 40 organ procurements were identified and potentially prevented by the checklist. Eighty-seven percent of fellows found the checklist to be unobtrusive to work flow, and 100% believed its use should be mandatory. Mortality was the same before and after implementation of the checklist despite increased patient volumes.

CONCLUSIONS

Implementation of a simple checklist for use during thoracic organ procurement uncovered a substantial number of near miss events. A preprocedural checklist for all thoracic organ transplants in the United States and abroad is feasible and would likely reduce adverse events.

SURGICAL SAFETY CHECKLIST: FROM IDEA TO PRACTICAL APPLICATION

Methods of surgical interventions performing, modifications, instruments used for operation became more developed every year. In spite of this fact, tendency of increase of the rate of iatrogenic errors took place and it was possible to prevent these mistakes by application of Surgical Safety Checklist. The «checklists» are easily available, not very expensive in practice and they are simple to use. An application of such questionnaires could improve the team work and understanding between members of the crew, which could influence directly on operation outcome. The article presents the history of creation of safety list, the analysis of efficacy of «checklist» application in clinical practice in different countries, information about controversial questions in «checklist», perspectives of its application.

Working towards safer surgery in Africa; a survey of utilization of the WHO safe surgical checklist at the main referral hospitals in East Africa

Background

Mortality from anaesthesia and surgery in many countries in Sub-Saharan Africa remain at levels last seen in high-income countries 70 years ago. With many factors contributing to these poor outcomes, the World Health Organization (WHO) launched the “Safe Surgery Saves Lives” campaign in 2007. This program included the design and implementation of the “Surgical Safety Checklist”, incorporating ten essential objectives for safe surgery. We set out to determine the knowledge of and attitudes towards the use of the WHO checklist for surgical patients in national referral hospitals in East Africa.

Methods

A cross-sectional survey was conducted at the main referral hospitals in Mulago (Uganda), Kenyatta (Kenya), Muhimbili (Tanzania), Centre Hospitalier Universitaire de Kigali (Rwanda) and Centre Hospitalo-Universitaire de Kamenge (Burundi). Using a pre-set questionnaire, we interviewed anaesthetists on their knowledge and attitudes towards use of the WHO surgical checklist.

Results

Of the 85 anaesthetists interviewed, only 25 % regularly used the WHO surgical checklist. None of the anaesthetists in Mulago (Uganda) or Centre Hospitalo-Universitaire de Kamenge (Burundi) used the checklist, mainly because it was not available, in contrast with Muhimbili (Tanzania), Kenyatta (Kenya), and Centre Hospitalier Universitaire de Kigali (Rwanda), where 65 %, 19 % and 36 %, respectively, used the checklist.

Conclusion

Adherence to aspects of care embedded in the checklist is associated with a reduction in postoperative complications. It is therefore necessary to make the surgical checklist available, to train the surgical team on its importance and to identify local anaesthetists to champion its implementation in East Africa. The Ministries of Health in the participating countries need to issue directives for the implementation of the WHO checklist in all hospitals that conduct surgery in order to improve surgical outcomes.

Team Training in the Perioperative Arena: A Methodology for Implementation and Auditing Behavior

Preventable medical errors in the operating room are most often caused by ineffective communication and suboptimal team dynamics. TeamSTEPPS is a government-funded, evidence-based program that provides tools and education to improve teamwork in medicine. The study hospital implemented TeamSTEPPS in the operating room and merged the program with a surgical safety checklist. Audits were performed to collect both quantitative and qualitative information on time out (brief) and debrief conversations, using a standardized audit tool. A total of 1610 audits over 6 months were performed by live auditors. Performance was sustained at desired levels or improved for all qualitative metrics using χ2 and linear regression analyses. Additionally, the absolute number of wrong site/side/person surgery and unintentionally retained foreign body counts decreased after TeamSTEPPS implementation.

Development and pilot study of an essential set of indicators for general surgery services

INTRODUCTION

At present there is a lack of appropriate quality measures for benchmarking in general surgery units of Spanish National Health System. The aim of this study is to present the selection, development and pilot-testing of an initial set of surgical quality indicators for this purpose.

METHODS

A modified Delphi was performed with experts from the Spanish Surgeons Association in order to prioritize previously selected indicators. Then, a pilot study was carried out in a public hospital encompassing qualitative analysis of feasibility for prioritized indicators and an additional qualitative and quantitative three-rater reliability assessment for medical record-based indicators. Observed inter-rater agreement, prevalence adjusted and bias adjusted kappa and non-adjusted kappa were performed, using a systematic random sample (n=30) for each of these indicators.

RESULTS

Twelve out of 13 proposed indicators were feasible: 5 medical record-based indicators and 7 indicators based on administrative databases. From medical record-based indicators, 3 were reliable (observed agreement >95%, adjusted kappa index >0.6 or non-adjusted kappa index >0.6 for composites and its components) and 2 needed further refinement.

CONCLUSIONS

Currently, medical record-based indicators could be used for comparison purposes, whilst further research must be done for validation and risk-adjustment of outcome indicators from administrative databases. Compliance results in the adequacy of informed consent, diagnosis-to-treatment delay in colorectal cancer, and antibiotic prophylaxis show room for improvement in the pilot-tested hospital.

Relationship Between Operating Room Teamwork, Contextual Factors, and Safety Checklist Performance

BACKGROUND

Studies show that using surgical safety checklists (SSCs) reduces complications. Many believe SSCs accomplish this by enhancing teamwork, but evidence is limited. Our study sought to relate teamwork to checklist performance, understand how they relate, and determine conditions that affect this relationship.

STUDY DESIGN

Using 2 validated tools for observing and coaching operating room teams, we evaluated the association between checklist performance with surgeon buy-in and 4 domains of surgical teamwork: clinical leadership, communication, coordination, and respect. Hospital staff in 10 South Carolina hospitals observed 207 procedures between April 2011 and January 2013. We calculated levels of checklist performance, buy-in, and measures of teamwork, and evaluated their relationship, controlling for patient and case characteristics.

RESULTS

Few teams completed most or all SSC items. Teams more often completed items considered procedural "checks" than conversation "prompts." Surgeon buy-in, clinical leadership, communication, a summary measure of teamwork overall, and observers' teamwork ratings positively related to overall checklist completion (multivariable model estimates from 0.04, p < 0.05 for communication to 0.17, p < 0.01 for surgeon buy-in). All measures of teamwork and surgeon buy-in related positively to completing more conversation prompts; none related significantly to procedural checks (estimates from 0.10, p < 0.01 for communication to 0.27, p < 0.001 for surgeon buy-in). Patient age was significantly associated with completing the checklist and prompts (p < 0.05); only case duration was positively associated with performing more checks (p < 0.10).

CONCLUSIONS

Surgeon buy-in and surgical teamwork characterized by shared clinical leadership, open communication, active coordination, and mutual respect were critical in prompting case-related conversations, but not in completing procedural checks. Findings highlight the importance of surgeon engagement and high-quality, consistent teamwork for promoting checklist use and ensuring a safe surgical environment.