Errors and Omissions in Anesthesia: A Pilot Study Using a Pilot???s Checklist

A simulation-based randomized trial of ABCDE style cognitive aid for emergency medical services CHecklist In Prehospital Settings: the CHIPS-study

BACKGROUND

Checklists are a powerful tool for reduction of mortality and morbidity. Checklists structure complex processes in a reproducible manner, optimize team interaction, and prevent errors related to human factors. Despite wide dissemination of the checklist, effects of checklist use in the prehospital emergency medicine are currently unclear. The aim of the study was to demonstrate that participants achieve higher adherence to guideline-recommended actions, manage the scenario more time-efficient, and thirdly demonstrate better adherence to the ABCDE-compliant workflow in a simulated ROSC situation.

METHODS

CHIPS was a prospective randomized case-control study. Professional emergency medical service teams were asked to perform cardiopulmonary resuscitation on an adult high-fidelity patient simulator achieving ROSC. The intervention group used a checklist which transferred the ERC guideline statements of ROSC into the structure of the 'ABCDE' mnemonic. Guideline adherence (performance score, PS), utilization of process time (items/minute) and workflow were measured by analyzing continuous A/V recordings of the simulation. Pre- and post-questionnaires addressing demographics and relevance of the checklist were recorded. Effect sizes were determined by calculating Cohen's d. The level of significance was defined at p < 0.05.

RESULTS

Twenty scenarios in the intervention group (INT) and twenty-one in the control group (CON) were evaluated. The average time of use of the checklist (CU) in the INT was 6.32 min (2.39-9.18 min; SD = 2.08 min). Mean PS of INT was significantly higher than CON, with a strong effect size (p = 0.001, d = 0.935). In the INT, significantly more items were completed per minute of scenario duration (INT, 1.48 items/min; CON, 1.15 items/min, difference: 0.33/min (25%), p = 0.001), showing a large effect size (d = 1.11). The workflow did not significantly differ between the groups (p = 0.079), although a medium effect size was shown (d = 0.563) with the tendency of the CON group deviating stronger from the ABCDE than the INT.

CONCLUSION

Checklists can have positive effects on outcome in the prehospital setting by significantly facilitates adherence to guidelines. Checklist use may be time-effective in the prehospital setting. Checklists based on the 'ABCDE' mnemonic can be used according to the 'do verify' approach. Team Time Outs are recommended to start and finish checklists.

Persisting high rates of omissions during anesthesia induction are decreased by utilization of a pre- & post-induction checklist

INTRODUCTION

Although Checklists (CL) for routine anesthesia cases have demonstrated their values in various studies, they have found little traction so far. While several reports have shown the benefit of CL preventing omissions prior to anesthesia induction, no investigation yet has scrutinized omissions during the post-induction phase immediately after intubation. This study evaluated the rate of omissions prior to and following the induction of non-emergent general anesthesia, as well as the impact of checklists on omission prevention.

METHODS

We performed a monocentric, prospective, observational study during induction of general anesthesia cases. We evaluated the omission rate made for the pre- as well as the immediate post-induction phase and determined the impact of pre-and post-induction CL on the rate of omission corrections. The CL used were introduced two years prior to the study. The observed providers were limited to those familiar with the institutional CL. Usage of CL was not mandated.

RESULTS

237 general anesthesia inductions were included in the observation. At least one omission in 32% of all cases in the pre-induction setup was found and in 40% within the immediate post-induction phases. CL significantly reduced omission rates (relative risk = 0.64, 95% CI = 0.45-0.92, p = 0.01).

CONCLUSION

Omission rates during the pre- and post-induction phases of routine general anesthesia procedures remain high. Pre- and post-induction CL have the potential to increase patient safety and should be considered for routine anesthesia with appropriate training provided.

Medical physics practice guideline 4.b: Development, implementation, use and maintenance of safety checklists

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8000 members and is the principal organization of medical physicists in the US. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the US. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines: Must and must not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline. While must is the term to be used in the guidelines, if an entity that adopts the guideline has shall as the preferred term, the AAPM considers that must and shall have the same meaning. Should and should not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

A Cognitive Aid Improves Adherence to Guidelines for Critical Endotracheal Intubation in the Resuscitation Room: A Randomized Controlled Trial With Manikin-Based In Situ Simulation

INTRODUCTION

Emergency endotracheal intubation (ETI) is a high-risk procedure. Some of its adverse events are life-threatening, and guidelines emphasize the need to anticipate complications by thorough preparation. The emergency department (ED) can be an unpredictable environment, and we tested the hypothesis that a cognitive aid would help the emergency practitioners better follow guidelines. The main objective of this study was to determine whether the use of a cognitive aid focusing on both preintubation and postintubation items could improve ETI preparation and implementation in the ED resuscitation room regarding adherence to guidelines. The secondary objective was to measure and describe procedure times.

METHODS

We conducted a single-blind randomized controlled trial with manikin-based in situ simulation. The participants were not aware of the purpose of the study. The cognitive aid was developed using national guidelines and current scientific literature. The most relevant items were the preparation and implementation of a rapid sequence induction for ETI followed by mechanical ventilation. Emergency department physician-nurse pairs were randomized into a "cognitive aid" group and a "control" group. All pairs completed the same scenario that led to ETI in their own resuscitation room. An adherence to guidelines score of 30, derived from the 30 items of the cognitive aid (1 point per item), and preparation and intubation times were collected.

RESULTS

Seventeen pairs were included in each group. Adherence to guidelines scores were significantly higher in the cognitive aid group than in the control group (median = 28 of 30, interquartile range = 25-28, vs. median = 24 of 30, interquartile range = 21-26, respectively, P < 0.01). Preparation, intubation, and total procedure times were slightly longer in the cognitive aid group, but these results were not significant.

CONCLUSIONS

In an in situ simulation, a cognitive aid for the preparation and implementation of an emergency intubation procedure in the ED resuscitation room significantly improved adherence to guidelines without increasing procedure times. Further work is needed in a larger sample and in different settings to evaluate the optimal use of cognitive aids in critical situations.

Intraoperative MR Imaging during Glioma Resection

One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.

Effects of prior exposure to a visual airway cognitive aid on decision-making in a simulated airway emergency: A randomised controlled study

BACKGROUND

Decision-making deficits in airway emergencies have led to adverse patient outcomes. A cognitive aid would assist clinicians through critical decision-making steps, preventing key action omission.

OBJECTIVE

We aimed to investigate the effects of a visual airway cognitive aid on decision-making in a simulated airway emergency scenario.

DESIGN

Randomised controlled study.

SETTING

Single-institution, tertiary-level hospital in Toronto, Canada from September 2017 to March 2019.

PARTICIPANTS

Teams consisting of a participant anaesthesia resident, nurse and respiratory therapist were randomised to intervention (N = 20 teams) and control groups (N = 20 teams).

INTERVENTION

Participants in both groups received a 15-min didactic session on crisis resource management which included teamwork communication and the concepts of cognitive aids for the management of nonairway and airway critical events. Only participants in the intervention group were familiarised, oriented and instructed on a visual airway cognitive aid that was developed for this study. Within 1 to 4 weeks after the teaching session, teams were video-recorded managing a simulated 'cannot intubate-cannot oxygenate' scenario with the aid displayed in the simulation centre.

MAIN OUTCOME MEASURES

Decision-making time to perform a front-of-neck access (FONA), airway checklist actions, teamwork performances and a postscenario questionnaire.

RESULTS

Both groups performed similar key airway actions; however, the intervention group took a shorter decision-making time than the control group to perform a FONA after a last action [mean ± SD, 80.9 ± 54.5 vs. 122.2 ± 55.7 s; difference (95% CI) -41.2 (-76.5 to -6.0) s, P = 0.023]. Furthermore, the intervention group used the aid more than the control group (63.0 vs. 28.1%, P < 0.001). Total time of scenario completion, action checklist and teamwork performances scores were similar between groups.

CONCLUSIONS

Prior exposure and teaching of a visual airway cognitive aid improved decision-making time to perform a FONA during a simulated airway emergency.

Does utilization of an intubation safety checklist reduce omissions during simulated resuscitation scenarios: a multi-center randomized controlled trial

Objectives

Checklists have been used to decrease adverse events associated with medical procedures. Simulation provides a safe setting in which to evaluate a new checklist. The objective of this study was to determine if the use of a novel peri-intubation checklist would decrease practitioners’ rates of omission of tasks during simulated airway management scenarios.

Methods

Fifty-four emergency medicine (EM) practitioners from two academic centers were randomized to either their usual approach or use of our checklist, then completed three simulated airway management scenarios. A minimum of two assessors documented the number of tasks omitted and the time until definitive airway management. Discrepancies between assessors were resolved by single assessor video review. Participants also completed a post-simulation survey.

Results

The average percentage of omitted tasks over three scenarios was 45.7% in the control group (n = 25) and 13.5% in the checklist group (n = 29)—an absolute difference of 32.2% (95% CI 27.8, 36.6%). Time to definitive airway management was longer in the checklist group in the first two of three scenarios (difference of 110.0 s, 95% CI 55.0 to 167.0; 83.0 s, 95% CI 35.0 to 128.0; and 36.0 s, 95% CI −18.0 to 98.0 respectively).

Conclusions

In this dual-center, randomized controlled trial, use of an airway checklist in a simulated setting significantly decreased the number of important airway tasks omitted by EM practitioners, but increased time to definitive airway management.

Electronic supplementary material

The online version of this article (10.1007/s43678-020-00010-w) contains supplementary material, which is available to authorized users.

ABCDE cognitive aid tool in patient assessment - development and validation in a multicenter pilot simulation study

Background

The so called ABCDE approach (Airway-Breathing-Circulation-Disability-Exposure) is a golden standard of patient assessment. The efficacy of using cognitive aids (CA) in resuscitation and peri-arrest situations remains an important knowledge gap. This work aims to develop an ABCDE CA tool (CAT) and study its potential benefits in patient condition assessment.

Methods

The development of the ABCDE CAT was done by 3 rounds of modified Delphi method performed by the members of the Advanced Life Support Science and Education Committee of the European Resuscitation Council.

A pilot multicentre study on 48 paramedic students performing patient assessment in pre-post cohorts (without and with the ABCDA CAT) was made in order to validate and evaluate the impact of the tool in simulated clinical scenarios.

The cumulative number and proper order of steps in clinical assessment in simulated scenarios were recorded and the time of the assessment was measured.

Results

The Delphi method resulted in the ABCDE CAT. The use of ABCDE CAT was associated with more performed assessment steps (804: 868; OR = 1.17, 95% CI: 1.02 to 1.35, p = 0.023) which were significantly more frequently performed in proper order (220: 338; OR = 1.68, 95% CI: 1.40 to 2.02, p < 0.0001). The use of ABCDE CAT did not prolong the time of patient assessment.

Conclusion

The cognitive aid for ABCDE assessment was developed. The use of this cognitive aid for ABCDE helps paramedics to perform more procedures, more frequently in the right order and did not prolong the patient assessment in advanced life support and peri-arrest care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-020-00390-3.

Why We Fail to Rescue During Critical Events

Many factors come together probabilistically to affect clinician response to critical events in the operating room; no 2 critical events are alike. These factors involve 4 primary domains: (1) the event itself, (2) the individual anesthetist(s), (3) the operating room team, and (4) the resources available and environments in which the event occurs. Appreciating these factors, anticipating how they create vulnerabilities for error and poor response, and actively addressing those vulnerabilities (before events occur as well as during) will help clinicians manage critical event response more effectively and avoid errors.

Checklist Design Reconsidered: Understanding Checklist Compliance and Timing of Interactions

We examine the association between user interactions with a checklist and task performance in a time-critical medical setting. By comparing 98 logs from a digital checklist for trauma resuscitation with activity logs generated by video review, we identified three non-compliant checklist use behaviors: failure to check items for completed tasks, falsely checking items when tasks were not performed, and inaccurately checking items for incomplete tasks. Using video review, we found that user perceptions of task completion were often misaligned with clinical practices that guided activity coding, thereby contributing to non-compliant check-offs. Our analysis of associations between different contexts and the timing of check-offs showed longer delays when (1) checklist users were absent during patient arrival, (2) patients had penetrating injuries, and (3) resuscitations were assigned to the highest acuity. We discuss opportunities for reconsidering checklist designs to reduce non-compliant checklist use.

Use of a Digital Cognitive Aid in the Early Management of Simulated War Wounds in a Combat Environment, a Randomized Trial

Introduction

The French army has implemented an algorithm based on the acronym “MARCHE RYAN,” each letter standing for a key action to complete in order to help first care providers during emergency casualty care. On the battlefield, the risk of error is increased, and the use of cognitive aids (CAs) might be helpful to avoid distraction. We investigated the effect of using a digital CA (MAX, for Medical Assistance eXpert) by combat casualty care providers on their technical and nontechnical performances during the early management of simulated war wounds, compared to their memory and training alone.

Materials and Methods

We conducted a randomized, controlled, unblinded study between July 2016 and February 2017. This study was approved by the Ethics Committee of the Ethical Board of Desgenettes Army Training Hospital (14.06.2017 n°385) and was registered on clinicaltrials.gov (NCT03483727). It took place during medicalization training in hostile environment (“MEDICHOS”) in Chamonix Mont-Blanc and in the first aid training center in La Valbonne military base (France). Each participant had to deal with two different scenarios, one with MAX (MAX+) and the other without (MAX−). Scenarios were held using either high-fidelity patient simulators or actors as wounded patients. The primary outcome was participants’ technical performance rated as their adherence to the MARCHE RYAN procedure (maximum 100%). The secondary outcome was the nontechnical performance according to the Ottawa crisis resource management Global Rating Scale (maximum 42).

Results

Technical performance was significantly higher in the MAX+ scenarios (70.60 IQR [63.70–73.56] than in the MAX− scenarios (56.25 IQR [52.88–62.09], p = 0.002). The Ottawa scores were significantly higher in the MAX+ scenarios (31.50 IQR [29.50–33.75]) than in the MAX− scenarios (29.50 IQR [24.50–32.00], p = 0.031).

Conclusions

The use of a digital CA by combat casualty care providers improved technical and nontechnical performances during field training of simulated crises. Following recommendations on the design and use of CA, regular team training would improve fluidity in the use and acceptance of an aid, by a highly drilled professional corporation with a strong culture of leadership. Digital CA should be tested at a larger scale in order to validate their contribution to real combat casualty care.

Using simulation to iteratively test and re-design a cognitive aid for use in the management of severe local anaesthetic toxicity

Introduction

Cognitive aids, such as a guideline for the management of severe local anaesthetic (LA) toxicity, are tools designed to help users complete a task. Human factors experts recommend the use of simulation to iteratively test and re-design these tools. The purpose of this study was to apply human factors engineering principles to the testing and iterative re-design of three existing cognitive aids used for the management of severe LA toxicity and to use these data to develop a ‘new’ cognitive aid.

Methods

Twenty anaesthetist–anaesthetic assistant pairs were randomised into four groups. Each of the first three groups received one of three different existing cognitive aids during a standardised simulated LA toxicity crisis. Postsimulation semistructured interviews were conducted to identify features beneficial and detrimental to the format and usability of the aid. Synthesis of the interview data with established checklist design recommendations resulted in a prototype aid, which was subjected to further testing and re-design by the fourth group (five more pairs) under the same conditions thus creating the final iteration of the new aid.

Results

Features of the new aid included a single-stream flowchart structure, single-sided, large-font design with colour contrast, simplified instructions and no need for calculations. This simplified tool contains only the information users reported as essential for the immediate crisis management.

Conclusions

Utilisation of formative usability testing and simulation-based user-centred design resulted in a visually very different cognitive aid and reinforces the importance of designing aids in the context in which they are to be used. Simplified tools may be more appropriate for use in emergencies but more detailed guidelines may be necessary for training, education and development of local standard operating procedures. Iterative simulation-based testing and re-design is likely to be of assistance when developing aids for other crises, and to eliminate design failure as a confounder when investigating the relationship between use of cognitive aids and performance.

The development and implementation of checklists in obstetrics

Checklists have been long used as a cognitive aid in various high-stakes environments to improve the reliability and performance of individuals and teams. When designed well, implemented thoughtfully, and monitored closely, they offer the opportunity to improve the performance of health care teams and advance patient safety. There are different types of checklists; examples include task lists, troubleshooting lists, coordination lists, discipline lists, and to-do lists. Each is useful in different situations and requires different implementation strategies. Checklists also are different from algorithms, care maps and protocols, and educational tools. Therefore, they are not useful in all situations. In appropriate selected clinical circumstances, checklists are tools that can help standardize care, improve communication, and help teams perform optimally.

Evaluating Checklist Use in Companion Animal Wellness Visits in a Veterinary Teaching Hospital: A Preliminary Study

The number of companion animal wellness visits in private practice has been decreasing, and one important factor cited is the lack of effective communication between veterinarians and pet owners regarding the importance of preventive care. Checklists have been widely used in many fields and are especially useful in areas where a complex task must be completed with multiple small steps, or when cognitive fatigue is evident. The use of checklists in veterinary medical education has not yet been thoroughly evaluated as a potential strategy to improve communication with pet owners regarding preventive care. The authors explored whether the use of a checklist based on the American Animal Hospital Association/American Veterinary Medical Association canine and feline preventive care guidelines would benefit senior veterinary students in accomplishing more complete canine and feline wellness visits. A group of students using provided checklists was compared to a control group of students who did not use checklists on the basis of their medical record notes from the visits. The students using the checklists were routinely more complete in several areas of a wellness visit vs. those who did not use the checklists. However, neither group of students routinely discussed follow-up care recommendations such as frequency or timing of follow-up visits. The study authors recommend considering checklist use for teaching and implementing wellness in companion animal primary care veterinary clinical teaching settings.

Exploring Design Opportunities for a Context-Adaptive Medical Checklist Through Technology Probe Approach

This paper explores the workflow and use of an interactive medical checklist for trauma resuscitation-an emerging technology developed for trauma team leaders to support decision making and task coordination among team members. We used a technology probe approach and ethnographic methods, including video review, interviews, and content analysis of checklist logs, to examine how team leaders use the checklist probe during live resuscitations. We found that team leaders of various experience levels use the technology differently. Some leaders frequently glance at the checklist and take notes during task performance, while others place the checklist on a stand and only interact with the checklist when checking items. We compared checklist timestamps to task activities and found that most items are checked off after tasks are performed. We conclude by discussing design implications and new design opportunities for a future dynamic, adaptive checklist.

Design In The Wild: Lessons From Researcher Participation In Design Of Emerging Technology

We describe a pilot study of designing and evaluating a digital checklist for medical emergencies based on participation of medical-expert researchers who used the checklist during actual trauma resuscitations. The participation of the researchers revealed challenges and insights for designing in the wild, as well as next steps for using our emerging technology in real scenarios.

Mode of Information Delivery Does Not Effect Anesthesia Trainee Performance During Simulated Perioperative Pediatric Critical Events: A Trial of Paper Versus Electronic Cognitive Aids

INTRODUCTION

Cognitive aids (CAs), including emergency manuals and checklists, have been recommended as a means to address the failure of healthcare providers to adhere to evidence-based standards of treatment during crisis situations. Unfortunately, users of CAs still commit errors, omit critical steps, fail to achieve perfect adherence to guidelines, and frequently choose to not use CA during both simulated and real crisis events. We sought to evaluate whether the mode in which a CA presents information (ie, paper vs. electronic) affects clinician performance during simulated critical events.

METHODS

In a prospective, randomized, controlled trial, anesthesia trainees managed simulated events under 1 of the following 3 conditions: (1) from memory alone (control), (2) with a paper CA, or (3) with an electronic version of the same CA. Management of the events was assessed using scenario-specific checklists. Mixed-effect regression models were used for analysis of overall checklist score and for elapsed time.

RESULTS

One hundred thirty-nine simulated events were observed and rated. Approximately, 1 of 3 trainees assigned to use a CA (electronic 29%, paper 36%) chose not to use it during the scenario. Compared with the control group (52%), the overall score was 6% higher in the paper CA group and 8% higher (95% confidence interval, 0.914.5; P = 0.03) in the electronic CA group. The difference between paper and electronic CA was not significant. There was a wide range in time to first use of the CA, but the time to task completion was not affected by CA use, nor did the time to CA use impact CA effectiveness as measured by performance.

CONCLUSIONS

The format (paper or electronic) of the CA did not affect the impact of the CA on clinician performance in this study. Clinician compliance with the use of the CA was unaffected by format, suggesting that other factors may determine whether clinicians choose to use a CA or not. Time to use of the CA did not affect clinical performance, suggesting that it may not be when CAs are used but how they are used that determines their impact. The current study highlights the importance of not just familiarizing clinicians with the content of CA but also training clinicians in when and how to use an emergency CA.

Inadvertent intrathecal injections and best practice management

The intrathecal space has become an important anatomic site for medical intervention not only in anesthesia practice, but also in many other medical specialties. Undesired/inadvertent intrathecal injections (UII) are generally rare. There is tremendous variation in reported inadvertent administrations via an intrathecal route in the literature, mainly as individual cases and very small case-series reports. This review aims to identify potential sources of UII, its clinical presentations, and appropriate management. The inadvertent injectants are classified as anesthetic agents and pain medicines, chemotherapeutics, radiological contrast agents, antibiotics and corticosteroids, and miscellaneous chemical agents such as tranexamic acid. The clinical effects of UII are dependent upon inadvertent injectant(s) and dose being administered intrathecally, and can range from no adverse effect to profound neurological consequences and/or death. Prompt cerebrospinal fluid (CSF) lavage and cardiopulmonary support seem to be the mainstay of treatment. If serious consequences are anticipated, CSF lavage could be lifesaving. This review additionally provides some options for comprehensive management and preventing strategies.

Inter-rater agreement and checklist validation for postoperative wound assessment using smartphone images in vascular surgery

OBJECTIVE

Surgical site infection (SSI) is the most common nosocomial infection, in vascular surgery patients, who experience a high rate of readmission. Facilitating transition from hospital to outpatient care with digital image-based wound monitoring has the potential to detect and to enable treatment of SSI at an early stage. In this study, we evaluated whether smartphone digital images can supplant in-person evaluation of postoperative vascular surgery wounds.

METHODS

We developed a wound assessment checklist using previously validated criteria. We recruited adults who underwent a vascular surgical procedure between 2014 and 2015, involving an incision of at least 3 cm, from a high-volume academic vascular surgery service. Vascular surgery care providers evaluated wounds in person using the assessment checklist; a different group of providers evaluated wounds by a smartphone digital image. Inter-rater agreement coefficients for wound characteristics and treatment plan were calculated within and between the in-person group and the digital image group; the sensitivity and specificity of digital images relative to in-person evaluation were determined.

RESULTS

We assessed a total of 80 wounds. Regardless of modality, inter-rater agreement was poor when wounds were evaluated for the presence of ecchymosis and redness; moderate for cellulitis; and high for the presence of a drain, necrosis, or dehiscence. As expected, the presence of drainage was more readily observed in person. Inter-rater agreement was high for both in-person and image-based assessment with respect to course of treatment, with near-perfect agreement for treatments ranging from antibiotics to surgical débridement to hospital readmission. No difference in agreement emerged when raters evaluated poor-quality compared with high-quality images. For most parameters, specificity was higher than sensitivity for image-based compared with "gold standard" in-person assessment.

CONCLUSIONS

Using smartphone digital images is a valid method for evaluating postoperative vascular surgery wounds and is comparable to in-person evaluation with regard to most wound characteristics. The inter-rater reliability for determining treatment recommendations was universally high. Remote wound monitoring and assessment may play an integral role in future transitional care models to decrease readmission for SSI in vascular or other surgical patients. These findings will inform smartphone implementation in the clinical care setting as wound images transition from informal clinical communication to becoming part of the care standard.

Using a Checklist to Improve Family Communication in Trauma Care

Modern concepts of patient-centered care emphasize effective communication with patients and families, an essential requirement in acute trauma settings. We hypothesized that using a checklist to guide the initial family conversation would improve the family's perception of the interaction. Institutional Review Board–approved, prospective pre/post study involving families of trauma patients admitted to our Level I trauma center for >24 hours. In the control group, families received information according to existing practices. In the study group, residents gave patient information to a first-degree family member using a checklist that guided the interaction. The checklist included a physician introduction, patient condition, list of known injuries, admission unit or intensive care unit, any consultants involved, plans for additional studies or operations, and opportunity for family to ask questions. An 11-item survey was administered 24 to 48 hours after admission to each group that evaluated the trauma team's communication in the areas of physician introduction, patient condition, ongoing treatment, and family perception of the interaction. Responses were on a Likert scale and analyzed using the Wilcoxon-Mann-Whitney test. There were 130 patients in each group. The study group had significantly ( P < 0.05) better responses in 8 of 11 items surveyed: physician spoke to family, physician introduction, understanding of their relative's injuries, admitting unit, consultants involved, urgent surgical procedures required, ongoing diagnostic studies, and understanding of the treatment plan. In conclusion, using a checklist improves the perception of the initial communication between the trauma team and family members of trauma patients, especially their understanding of the treatment plan.

An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams

BACKGROUND

An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked).

METHODS

A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork.

RESULTS

One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P < 0.001), knowledge of critical information: 100% vs 90% (P < 0.001), perception of safety: 91% vs 84% (P < 0.001), perception of teamwork: 90% vs 86% (P = 0.028), and clinical performance: 93% vs 93% (P = 0.60).

CONCLUSIONS

This study provides empirical evidence that the use of a preinduction checklist significantly improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams-all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork.

Checklists and Other Cognitive Aids For Emergency And Routine Anesthesia Care-A Survey on the Perception of Anesthesia Providers From a Large Academic US Institution

Background:

The use of printed or electronic checklists and other cognitive aids has gained increasing interest from anesthesia providers and professional societies. While these aids are not currently considered standard of care, the perceptions of the clinician might have an impact on their adoption.

Objectives:

We conducted a comprehensive survey to study the current opinions of anesthesia provider on the use of checklists and other cognitive aids.

Patients and Methods:

A questionnaire was developed by a departmental checklist focus group, which aimed to identify the perception of health care checklists in general as well as specific checklists for routine and crisis situations in anesthesia. Furthermore participants were asked regarding their perception of performing routine anesthesia and managing crisis situations without any cognitive aids. Using a web-based system, the survey was administered to all anesthesia providers at a single large United States academic medical center (University of California San Francisco). Demographic information included professional status (faculty, anesthesia resident, or nurse anesthetists [certified registered nurse anesthetists; CRNA]) and years of clinical experience.

Results:

69% of 312 providers responded. 98% of the survey takers consider the procedural time-out (the widely used pre-incision operating room checklist) as important or very important. We found that many anesthesia providers acknowledged limitations in their ability to perform clinical tasks without any lapses, and a majority would use checklists and other cognitive aids if available. Their acceptances are especially high for crisis situations (87 - 97%, depending on years of experience) and routine care that providers do not perform often (76 - 91%). Printed or electronic aids for patient-care transition and shift hand-offs were also valued (61% and 58%). To prepare for and perform routine anesthesia care, 40% of providers claimed interest in using checklists, however, the interest differed significantly with clinical experience: While both the least and most experienced providers valued aids for routine anesthesia (54% and 50%), only 29% of providers with 2 - 10 years of anesthesia experience claimed interest in using them. Distraction from patient care and decreased efficiency were concerns expressed for the use of routine checklist (27% and 31%, respectively). The main factors found to support the successful implementation of checklists into clinical care are ease of use and thoughtful integration into the anesthesia workflow.

Conclusions:

Providers at our large academic institution generally embrace the concept of checklists and other cognitive aids. This was true for all providers for checklists for procedural time outs, anesthesia crisis situations and those for routine procedures that providers rarely perform. Only very experienced and very junior providers appreciated the use of checklists for routine care. There remains a discrepancy between these claims and provider’s perception on their clinical competency based on memory alone.

Postgraduate education needs of Nurses' who are caregivers for patients with diabetes

Objective:

Diabetic management process requires nurses with expert knowledge and patient care skills. This study was carried out to identify nurses’ diabetic care approaches and their post graduate education needs in order to develop a “Basic Diabetes Patient Care Education Program” in a university hospital in Turkey.

Methods:

The descriptive study, using the survey technique, was carried out in a university hospital with 87 bedside nurses who were caring for diabetic patients. Investigators developed data collection tool consisting of closed ended questions and opportunities for open-ended responses.

Results:

Among the 87 nurses, 88.5% were staff nurses, and 11.5% were nurse managers. The mean age was 27.41 ± 4.82 and years of professional experience was 6.86 ± 4.23. The 41.4% of nurses stated that they were caring for 1-2 patients with diabetes per week and 72.4% of nurses stated that they had attended an educational session about diabetes after graduation. The 95.4% of nurses reported a need for a continuous education program for diabetes patient care. Medication regimen (69.0%) and special care applications such as wound care (54.0%) were the most needed educational requirements. There were no difference in educational needs based on basic education or years of professional experience (p>0.05).

Conclusions:

Nurses caring for patients with diabetes should be supported by orientation, in-service education and continuing education programs. Additionally, the placement of patient care courses for chronic diseases, like diabetes, into the core curriculum of nursing schools would be useful in responding to actual patient care and family needs.

Efficacy of a checklist-style structured radiology reporting template in reducing resident misses on cervical spine computed tomography examinations

The increasing use of medical checklists to promote patient safety raises the question of their utility in diagnostic radiology. This study evaluates the efficacy of a checklist-style reporting template in reducing resident misses on cervical spine CT examinations. A checklist-style reporting template for cervical spine CTs was created at our institution and mandated for resident preliminary reports. Ten months after implementation of the template, we performed a retrospective cohort study comparing rates of emergent pathology missed on reports generated with and without the checklist-style reporting template. In 1,832 reports generated without using the checklist-style template, 25 (17.6%) out of 142 emergent findings were missed. In 1,081 reports generated using the checklist-style template, 13 (11.9%) out of 109 emergent findings were missed. The decrease in missed pathology was not statistically significant (p = 0.21). However, larger differences were noted in the detection of emergent non-fracture findings, with 17 (28.3%) out of 60 findings missed on reports without use of the checklist template and 5 (9.3%) out of 54 findings missed on reports using the checklist template, representing a statistically significant decrease in missed non-fracture findings (p = 0.01). The use of a checklist-style structured reporting template resulted in a statistically significant decrease in missed non-fracture findings on cervical spine CTs. The lack of statistically significant change in missed fractures was expected given that residents' search patterns naturally include fracture detection. Our findings suggest that the use of checklists in structured reporting may increase diagnostic accuracy.

Medical Physics Practice Guideline 4.a: Development, implementation, use and maintenance of safety checklists

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.

The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.

Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.

The following terms are used in the AAPM practice guidelines:

Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline.

Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass

OBJECTIVE

Separation from cardiopulmonary bypass (CPB) requires multiple preparatory steps, during which mistakes, omissions, and human errors may occur. Checklists have been used extensively in aviation to improve performance of complex, multistep tasks. The aim of this study was to (1) develop a checklist using a modified Delphi process to identify essential steps necessary to prepare for separation from CPB, and (2) compare the frequency of completed items with and without the use of a checklist in simulation. It was hypothesized that the use of a checklist would reduce the number of omissions.

DESIGN

High-fidelity simulation study.

SETTING

University-affiliated tertiary care facility.

PARTICIPANTS

Seven cardiac anesthesiologists created a checklist using a modified Delphi process. Ten residents participated in 4 scenarios separating from CPB in simulation.

INTERVENTIONS

Each scenario was performed first without a checklist and then again with a checklist. An observer graded participants' performance.

MEASUREMENTS AND MAIN RESULTS

A pre-separation checklist containing 9 tasks was created using the Delphi process. Without using this checklist, 4 tasks were completed in at least 75% of scenarios, and 8 tasks were completed at least 75% of the time when using the checklist. There was a significant improvement in completion of 5 of the 9 items (p< 0.01).

CONCLUSIONS

A modified Delphi process can be used to create a checklist of steps in preparing to separate from CPB. Using this checklist during simulation resulted in increased frequency of completing designated tasks in comparison to relying on memory alone. Checklists may reduce omission errors during complex periods of anesthesiologists' perioperative workflow.

Cognitive and system factors contributing to diagnostic errors in radiology

OBJECTIVE

In this article, we describe some of the cognitive and system-based sources of detection and interpretation errors in diagnostic radiology and discuss potential approaches to help reduce misdiagnoses.

CONCLUSION

Every radiologist worries about missing a diagnosis or giving a false-positive reading. The retrospective error rate among radiologic examinations is approximately 30%, with real-time errors in daily radiology practice averaging 3-5%. Nearly 75% of all medical malpractice claims against radiologists are related to diagnostic errors. As medical reimbursement trends downward, radiologists attempt to compensate by undertaking additional responsibilities to increase productivity. The increased workload, rising quality expectations, cognitive biases, and poor system factors all contribute to diagnostic errors in radiology. Diagnostic errors are underrecognized and underappreciated in radiology practice. This is due to the inability to obtain reliable national estimates of the impact, the difficulty in evaluating effectiveness of potential interventions, and the poor response to systemwide solutions. Most of our clinical work is executed through type 1 processes to minimize cost, anxiety, and delay; however, type 1 processes are also vulnerable to errors. Instead of trying to completely eliminate cognitive shortcuts that serve us well most of the time, becoming aware of common biases and using metacognitive strategies to mitigate the effects have the potential to create sustainable improvement in diagnostic errors.

Adherence Engineering

Checklists, with their goal to increase adherence to protocols, are gaining popularity in health care despite some serious limitations. Here I present adherence engineering (AE), a conceptual framework that aims to increase adherence to protocols. AE provides guidance for the development of equipment that supports the successful completion of structured tasks. An example of how AE principles might be implemented is shown in the context of a clinical task in health care. Nonadherence to protocol when performing this task can have severe consequences for patient safety. The application of AE has the potential to improve human performance in a wide range of contexts.

Developing content for a process-of-care checklist for use in intensive care units: a dual-method approach to establishing construct validity

Background

In the intensive care unit (ICU), checklists can be used to support the delivery of quality and consistent clinical care. While studies have reported important benefits for clinical checklists in this context, lack of formal validity testing in the literature prompted the study aim; to develop relevant ‘process-of-care’ checklist statements, using rigorously applied and reported methods that were clear, concise and reflective of the current evidence base. These statements will be sufficiently instructive for use by physicians during ICU clinical rounds.

Methods

A dual-method approach was utilized; semi-structured interviews with local clinicians; and rounds of surveys to an expert Delphi panel. The interviews helped determine checklist item inclusion/exclusion prior to the first round Delphi survey. The panel for the modified-Delphi technique consisted of local intensivists and a state-wide ICU quality committee. Minimum standards for consensus agreement were set prior to the distribution of questionnaires, and rounds of surveys continued until consensus was achieved.

Results

A number of important issues such as overlap with other initiatives were identified in interviews with clinicians and integrated into the Delphi questionnaire, but no additional checklist items were suggested, demonstrating adequate checklist coverage sourced from the literature. These items were verified by local clinicians as being relevant to ICU and important elements of care that required checking during ward rounds. Two rounds of Delphi surveys were required to reach consensus on nine checklist statements: nutrition, pain management, sedation, deep vein thrombosis and stress ulcer prevention, head-of-bed elevation, blood glucose levels, readiness to extubate, and medications.

Conclusions

Statements were developed as the most clear, concise, evidence-informed and instructive statements for use during clinical rounds in an ICU. Initial evidence in support of the checklist’s construct validity was established prior to further prospective evaluation in the same ICU.

Human Factors in Critical Care Medical Environments

The purpose of this chapter on human factors in critical care medical environments is to provide a systematic review of the human factors and ergonomics contributions that led to significant improvements in patient safety over the last five decades. The review will focus on issues that contributed to patient injury and fatalities and how human factors and ergonomics can improve performance of providers in critical care. Given the complexity of critical care delivery, a review needs to cover a wide range of subjects. In this review, I take a sociotechnical systems perspective on critical care and discuss the people, their technical and nontechnical skills, the importance of teamwork, technology, and ergonomics in this complex environment. After a description of the importance of a safety climate, the chapter will conclude with a summary on how human factors and ergonomics can improve quality in critical care delivery.

Validating a process-of-care checklist for intensive care units

Early evidence suggests that checklists are one way of ensuring required processes of care are delivered to intensive care unit patients. Evidence to date however, has not explicitly detailed methods of checklist validation in these settings. This study aimed to test the validity of a 'process-of-care' checklist for measuring and ensuring daily care delivery in an intensive care unit. A retrospective audit of a random selection of patient medical records was undertaken to compare with checklist data completed during the same time frame. Documentation in the patients' medical records was used as a proxy measure for actual completion of care. A specific audit tool extracted information from both the checklist and the medical record on the following processes of care: nutrition, weaning from ventilation, pain, glucose control, sit out of bed, bowel management, deep vein thrombosis and stress ulcer prophylaxis. These two data sources were compared using the Spearman's rho correlation coefficient. The two forms of documentation were significantly correlated (P=0.01) for all but one of the checklist items (pain). Findings provided support for the concurrent validity of an intensive care unit process-of-care checklist. Further research is required for checklist validity and reliability testing prior to, or in conjunction with, a planned prospective intervention study.

Communication interventions to improve adherence to infection control precautions: a randomised crossover trial

Background

Ineffective communication of infection control requirements during transitions of care is a potential cause of non-compliance with infection control precautions by healthcare personnel. In this study, interventions to enhance communication during inpatient transfers between wards and radiology were implemented, in the attempt to improve adherence to precautions during transfers.

Methods

Two interventions were implemented, comprising (i) a pre-transfer checklist used by radiology porters to confirm a patient’s infectious status; (ii) a coloured cue to highlight written infectious status information in the transfer form. The effectiveness of the interventions in promoting adherence to standard precautions by radiology porters when transporting infectious patients was evaluated using a randomised crossover trial at a teaching hospital in Australia.

Results

300 transfers were observed over a period of 4 months. Compliance with infection control precautions in the intervention groups was significantly improved relative to the control group (p < 0.01). Adherence rate in the control group was 38%. Applying the coloured cue resulted in a compliance rate of 73%. The pre-transfer checklist intervention achieved a comparable compliance rate of 71%. When both interventions were applied, a compliance rate of 74% was attained. Acceptability of the coloured cue was high, but adherence to the checklist was low (40%).

Conclusions

Simple measures to enhance communication through the provision of a checklist and the use a coloured cue brought about significant improvement in compliance with infection control precautions by transport personnel during inpatient transfers. The study underscores the importance of effective communication in ensuring compliance with infection control precautions during transitions of care.

The effect of a checklist on the quality of post-anaesthesia patient handover: a randomized controlled trial

OBJECTIVE

Patient handover is an important element of continuity, quality and safety in patient care. Handover without standardized protocols is prone to information loss and might be a possible danger to patient safety. Checklists are established methods that help to structure complex processes in other high-risk fields such as aviation. In the past few years, their implementation has attracted research interest in medicine. We hypothesize that a checklist for handover between anaesthesiologist and post-anaesthesia care unit nurse will increase the amount of information transfer during patient handover after anaesthesia.

DESIGN AND SETTING

A total of 120 post-anaesthesia patient handovers were recorded on video and analyzed. Forty handovers before the implementation of the checklist and 80 after the implementation of the checklist, randomized into two groups: with and without the use of the checklist.

MAIN OUTCOME MEASURES

An overall number of items handed over, handover of specific items and duration of the handover were analyzed.

RESULTS

With the use of the written checklist, the overall items handed over increased significantly from a median of 32.4-48.7%. The duration of handover increased from a median of 86-121 s. Instructions about items that should be included in handovers, but without the use of a written checklist, was not associated with an increase in the number of items handed over or duration of the interview.

CONCLUSIONS

This study suggests that the use of a checklist for post-anaesthesia handover might improve the quality of patient handover by increasing the information handed over.

An audit of level two and level three checks of anaesthesia delivery systems performed at three hospitals in South Australia

Anaesthetists may subject patients to unnecessary risk by not checking anaesthetic equipment thoroughly before use. Numerous adverse events have been associated with failure to check equipment. The Australian and New Zealand College of Anaesthetists and anaesthetic delivery system manufactures have made recommendations on how anaesthetic equipment should be maintained and checked before use and for the training required for staff who use such equipment. These recommendations are made to minimise the risk to patients undergoing anaesthesia. This prospective audit investigated the adherence of anaesthetic practitioners to a selection of those recommendations. Covert observations of anaesthetic practitioners were made while they were checking their designated anaesthetic machine, either at the beginning of a day's list or between cases. Structured interviews with staff who check the anaesthetic machine were carried out to determine the training they had received. The results indicated poor compliance with recommendations: significantly, the backup oxygen cylinders' pressure/contents were not checked in 45% of observations; the emergency ventilation device was not checked in 67% of observations; the breathing circuit was not tested between patients in 79% of observations; no documentation of the checks performed was done in any cases; and no assessment or accreditation of the staff who performed these checks was performed. It was concluded that the poor compliance was a system failing and that patient safety might be increased with training and accrediting staff responsible for checking equipment, documenting the checks performed, and the formulation and use of a checklist.

Neurosurgical checklists: a review

Morbidity due to avoidable medical errors is a crippling reality intrinsic to health care. In particular, iatrogenic surgical errors lead to significant morbidity, decreased quality of life, and attendant costs. In recent decades there has been an increased focus on health care quality improvement, with a concomitant focus on mitigating avoidable medical errors. The most notable tool developed to this end is the surgical checklist. Checklists have been implemented in various operating rooms internationally, with overwhelmingly positive results. Comparatively, the field of neurosurgery has only minimally addressed the utility of checklists as a health care improvement measure. Literature on the use of checklists in this field has been sparse. Considering the widespread efficacy of this tool in other fields, the authors seek to raise neurosurgical awareness regarding checklists by reviewing the current literature.