A new journal devoted to patient safety in surgery: the time is now!

Effect of Alginate Gelatin Hydrogel Composited with Nano-Zinc on Cesarean Section Wound Healing

The Surgical procedure of cesarean section (CS) causes a large wound that any delay in its healing could increase the rate of stress, inconvenience, and dissatisfaction among the women who underwent CS procedure about six weeks after childbirth. The present study is trying to evaluate the effect of alginate and gelatin hydrogel composited with nanozinc effective extensibility and compressibility as a wound dressing nursing care after CS. The number of participants was 700 individuals enrolled all who underwent C-sections at Medical College in the Second Affiliated Hospital of Xi'an Jiaotong University (from September 2017 until September 2020). Patients were divided into two groups of case and control consist of 350 cases. The case group was treated with alginate gelatin hydrogel-nZnO+antibacterial wound dress and the control group was treated with wound healing ordinary creams+antibacterial. Three and four weeks following CS, the healing process of the wound was evaluated using REEDA wound scale. In the current study, there was not any significant difference between the studied case and control group in respect to individual's demographical characteristics such as economic status, educational level, BMI, and age. (P > 0.05). Also, we observed that patients treated with alginate gelatin hydrogel-nZnO would experience a significantly lower score for redness, ecchymosis, edema, and approximation of CS wound in comparison to the control group (P < 0.05). Also, slope analysis showed that the healing process was significantly quicker in patients treated with alginate gelatin hydrogel-nZnO in comparison to the control group. Finally, it was observed that more than 80% of patients did not represent any major sign of CS after three weeks, however, in the control case this issue was estimated at 50.6%. No allergic reaction has been observed. Our results showed that using alginate gelatin hydrogel-nZnO wound dress could be a novel treatment in a nursing care setting to decrease the CS wound complication and increase the healing process without any allergic reaction.

Visual differentiation and recognition memory of look-alike drug names: effects of disfluent format, text enhancement and exposure time

Three computer-based experiments were conducted to examine whether disfluent format, enhanced text, and increased exposure time improve the accuracy of visual differentiation and recognition memory of look-alike drug names. A three-way, repeated-measures look-alike drug name differentiation test assessed the visual differentiation accuracy of 30 nursing students (Experiment 1) and 15 nurses (Experiment 2). A two-way, repeated-measures recognition memory test examined the recognition memory accuracy of 15 nurses for look-alike drug names (Experiment 3). We found that making drug names disfluent did not significantly improve differentiation (Experiment 2) or memory accuracy (Experiment 3), but even impaired differentiation accuracy (Experiment 1). Enhanced text and longer exposure time significantly improved differentiation accuracy (Experiments 1 and 2). However, the enhanced text did not improve recognition memory (Experiment 3). We suggest that making look-alike drug names disfluent is not favourable. Enhanced text and longer exposure times are effective in supporting visual differentiation of look-alike drug names. Practitioner Summary: Confusion arising from look-alike drug names may compromise patient safety. Three experiments examined the effects of disfluent format, text enhancement and increased exposure time on visual and memory performances. Making drug names more difficult to read did not improve performance. Enhancing text design and increasing exposure (i.e. reading) time improved visual differentiation between medications, but did not improve the recognition of medications from memory. Abbreviations: SEEV: Salience-effort-expectancy-value; FDA: Food and Drug Administration; ANOVA: analysis of variance; SD: standard deviation, DF: disfluent format; TE: text enhancement; ET: exposure time.

Can universal patient-held health booklets promote continuity of care and patient-centred care in low-resource countries? The case of Mongolia

BACKGROUND

A system of clinical records accessible by both patients and their attending healthcare professionals facilitates continuity of care and patient-centred care, thereby improving clinical outcomes. The need for such a system has become greater as the proportion of patients with chronic non-communicable diseases (NCDs) requiring ongoing care increases. This is particularly true in low-income and middle-income countries where the burden of these diseases is greatest.

OBJECTIVE

To describe a nationwide patient-held health booklet (PHHB) system and investigate its use and completeness for clinical information transfer during chronic NCD outpatient visits in Ulaanbaatar, Mongolia.

METHODS

Qualitative and quantitative methodologies were employed in this mixed-methods study. Structured interviews were used to study a sample of adult patients with chronic NCDs attending the outpatient departments (OPDs) of two large, public secondary care hospitals ; artefact reviews were used to analyse the content of the written documents relating to their clinical care; and snowball methodology was used to identify policy and training documents.

RESULTS

96% (379/395) brought handover documentation from previous provider/s: 94% had PHHBs, 27% other additional documents and 4% had nothing. 67% were referred from primary care and 44% referred back for follow-up. On leaving the OPD, irrespective of requirements for computer data entry, doctors provided written clinical information in the PHHB for 93% of patients. 84% of patients recalled being given verbal information. However, only 41% of the consultation with written information included all three key handover information items (diagnosis, management/treatment and follow-up). The PHHBs were the best completed type of document, with evidence that they were consulted by patients (80%), public (95%) and private (77%) providers. Living >1 hour away (OR=0.28; 95% CI 0.13 to 0.61) decreased the likelihood of receiving written management/treatment information; living >1 hour away (OR=0.48; 95% CI 0.27 to 0.87), comorbidity (OR=0.55; 95% CI 0.35 to 0.87) and returning to secondary care (OR=0.52; 95% CI 0.33 to 0.80) all independently decreased the likelihood of receiving written follow-up information. A Ministry order mandates the use of the booklet, but there were no other related policies, guidelines or clinician training.

CONCLUSION

The universal PHHBs were well accepted, well used and the best completed handover documentation. The PHHBs provided a successful handover option for patients with chronic NCDs in Mongolia, but their completeness needs improving. There is potential for global application.

Improving Care Transitions in Healthcare: A Human Factors/Ergonomics (HFE) Approach

Delivering safe healthcare often involves multi-disciplinary teams working across multiple locations. Care transitions are required to provide continuity of care and are often fail due to this type of complexity. Care transitions occur in numerous settings, for example: during shift changes, transfer between wards, or during discharge to the patient’s home (WHO Collaborating Centre for Patient Safety Solutions 2007). The aim of the panel will be to discuss different types of care transitions and how HFE can assist in improving patient safety and efficiency of the process. The panel will discuss and share lessons learnt from a range of projects involving care transitions for pediatric trauma care (Woolridge), and barriers and facilitators to follow-up care for bone marrow transplant survivors (Sesto). In addition, the work system elements for care transitions for elective orthopedic patients (Carman), elderly patients after heart failure hospitalization (Holden) and risks to elderly patients’ safe medication management (Gurses) when transitioning from hospital to home will be discussed.

Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards

Background

Intravenous potassium chloride (IV KCl) solutions are widely used in hospitals for treatment of hypokalemia. As ampoules of concentrated KCL must be diluted before use, critical incidents have been associated with its preparation and administration. Currently, we have introduced ready-to-use diluted KCl infusion solutions to minimize the use of high-alert concentrated KCl. Since this process may be associated with considerable risks, we embraced a proactive hazard analysis as a tool to implement a change in high-alert drug usage in a hospital setting.

Methods

Failure mode and effect analysis (FMEA) is a systematic tool to analyze and identify risks in system operations. We used FMEA to examine the hazards associated with the implementation of the ready-to-use solutions. A multidisciplinary team analyzed the risks by identifying failure modes, conducting a hazard analysis and calculating the criticality index (CI) for each failure mode. A 1-day survey was performed as an evaluation step after a trial run period of approximately 4 months.

Results

Six major possible risks were identified. The most severe risks were prioritized and specific recommendations were formulated. Out of 28 patients receiving IV KCl on the day of the survey, 22 received the ready-to-use solutions and 6 received the concentrated solutions as instructed. Only 1 patient received inappropriate ready-to-use KCl.

Conclusions

Using the FMEA tool in our study has proven once again that by creating a gradient of severity of potential vulnerable elements, we are able to proactively promote safer and more efficient processes in health care systems. This article presents a utilization of this method for implementing a change in hospital policy regarding the routine use of IV KCl.

Do we need animal hands-on courses for transplantation surgery?

BACKGROUND

Transplantation surgery requires many years of training. This study evaluates and presents the results of our recent four-yr animal hands-on courses of transplantation surgery on participants' training.

METHODS

Since 2008, five two-d hands-on courses of transplantation surgery were performed on swine models at our department. Sixty-one participants were asked to answer three questionnaires (pre-course, immediate post-course, subsequent post-course). The questions pertained to their past education, expectations, and evaluation of our courses, as well as our course's effectiveness in advancing their surgical abilities. The results were analyzed, compared and are presented herein.

RESULTS

On average, 1.8 multiorgan procurements, 2.3 kidney, 1.5 liver, and 0.7 pancreas transplantations were performed by each participant. 41.7% of participants considered their previous practical training only satisfactory; 85% hoped for more opportunities to practice surgery; 73.3% evaluated our courses as very good; and 95.8% believed that our courses had fulfilled their expectations. 66% found the effectiveness of our course in advancing their surgical abilities very good; 30% good, and 4% satisfactory.

CONCLUSION

Animal hands-on courses of transplantation surgery are one of the best options to learn and practice different operations and techniques in a near to clinical simulated model. Regular participation in such courses with a focus on practical issues can provide optimal opportunities for trainees with the advantage of direct mentoring and feedback.

Developing a weekly patient safety and quality meeting in a medium-sized GI surgical unit in the United Kingdom

Background

Morbidity and Mortality (M&M) meetings are advocated as part of good surgical practice, but have been criticised as a method of improving patient outcomes. Several groups have re-designed the format of M&M meetings to improve reporting of complications, near misses and maximise learning points. As a medium sized department of 8 GI surgeons in the UK, we wished to explore and discuss the complications encountered in our clinical practice in more detail than currently available in our monthly M&M/audit meeting, in order to try and improve the quality of care we deliver to our patients. This article describes the practicalities of introducing a weekly meeting and reports on the initial data generated from the patients discussed.

Methods

Four groups of general surgical patients (both elective and acute) are discussed in depth at the weekly meeting- a) patients whose length of in-patient stay is greater than 7 days (as a surrogate marker of a complicated surgical episode), b) unplanned patient readmissions to our hospital (under any specialty) within 30 days of a previous discharge from the GI surgical service, c) all GI surgical inpatient deaths and d) returns to theatre within the same admission (either planned or unplanned).

Results

The initial data generated from the meeting first six months of the meeting are presented e.g.– 302 length of stay greater than 7 days patient episodes (attributable to complications in 26%, normal variant of disease in 59% and social reasons delaying discharge in 15%).

Conclusions

We feel that these weekly meetings can be helpful in addressing both patient safety and quality issues in more depth than the traditional M&M format, as well as being a valuable training resource for both surgical trainees and consultants alike.

Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department-inpatient admission handoffs

OBJECTIVE

To examine how clinicians on the receiving end of admission handoffs use electronic health records (EHRs) in preparation for those handoffs and to identify the kinds of impacts such usage may have.

MATERIALS AND METHODS

This analysis is part of a two-year ethnographic study of emergency department (ED) to internal medicine admission handoffs at a tertiary teaching and referral hospital. Qualitative data were gathered and analyzed iteratively, following a grounded theory methodology. Data collection methods included semi-structured interviews (N = 48), observations (349 hours), and recording of handoff conversations (N = 48). Data analyses involved coding, memo writing, and member checking.

RESULTS

The use of EHRs has enabled an emerging practice that we refer to as pre-handoff "chart biopsy": the activity of selectively examining portions of a patient's health record to gather specific data or information about that patient or to get a broader sense of the patient and the care that patient has received. Three functions of chart biopsy are identified: getting an overview of the patient; preparing for handoff and subsequent care; and defending against potential biases. Chart biopsies appear to impact important clinical and organizational processes. Among these are the nature and quality of handoff interactions, and the quality of care, including the appropriateness of dispositioning of patients.

CONCLUSIONS

Chart biopsy has the potential to enrich collaboration and to enable the hospital to act safely, efficiently, and effectively. Implications for handoff research and for the design and evaluation of EHRs are also discussed.

Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective

Background

With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.

Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.

Discussion

The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.

In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.

Summary

It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.

Hospital handoffs as multifunctional situated routines: implications for researchers and administrators

Patient handoffs involve the exchange of information between health professionals accompanying a transfer of responsibility for, or control of, a patient. Concerns over the safety risks of poor handoffs have resulted in regulatory pressure to standardize practice and considerable growth in research. But handoffs involve more than information transfer, and their consequences for health care organizations extend beyond the safety of patients. Using an organization theory lens, we review the literature on handoffs and propose a framework that characterizes handoffs as multifunctional, situated organizational routines. We also identify implications for researchers and hospital policymakers. Standardization and improvement efforts run the risk of causing unintended problems if they overlook the complexity of handoff and the larger organizational functions it serves. Deepening our understanding of the multifunctional, situated nature of handoff can lead to improvement efforts that not only safeguard individual patients, but also enhance the capabilities of the larger health care organization.

ISBAR for clear communication: one hospital's experience spreading the message

All health services rely on efficient and accurate communication between health professionals to ensure safe and effective patient care. Our health service introduced a standardised technique, ISBAR (Identify, Situation, Background, Assessment, Request), for telephone communication. We describe and evaluate the implementation of this project; evaluation was undertaken using program logic mapping. Recommendations for other health services planning to introduce communication tools into routine clinical use are also provided.