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

Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis

BACKGROUND

Surgical safety checklists reduce adverse events, but monitoring adherence to checklists is confounded by observation bias. The ORBB platform can monitor checklist compliance and correlate compliance with outcomes. This study aims to evaluate the association between checklist compliance and patient outcomes using the ORBB platform.

METHODS

This is a retrospective analysis of data from the electronic medical record of cases performed in ORBB-equipped operating rooms at a single quaternary referral center. All patients who did not opt out and underwent surgery at UT Southwestern Medical Center in ORBB-equipped rooms from August 2020 to September 2022 were included. The ORBB platform was set-up in five operating rooms and surgical safety checklist compliance was monitored by way of AI-based video review.

RESULTS

Overall, 4581 patients were included in this analysis.. Performance on the checklist was associated with lower mortality (OR, 0.96; 95% CI, 0.94-0.98; P < 0.05), and decreased length of stay (estimate [E]: -0.02 days; 95% CI, -0.03 to -0.005; P < 0.05). Performance during "timeouts" was associated with mortality (OR, 0.97; 95% CI, 0.94-0.99; P < 0.05). "Debriefings" were independently associated with mortality (OR, 0.98; 95% CI, 0.96-0.99; P < 0.05), length of stay (Estimate, -0.0009 days; 95% CI, -0.02 to -0.001; P < 0.05), and ICU admission (OR, 0.99; 95% CI, 0.98-0.99; P < 0.05).

CONCLUSION

Procedures performed by surgical teams who performed better on the surgical safety checklist tended to have better outcomes. This innovative technology could substantially enhance our ability to understand and mitigate threats to patients in real-time.

Prevalence and characteristics of the 'bad feeling' among healthcare professionals in the context of emergency situations: A Bi-Hospital Survey

INTRODUCTION

Clinical decision-making is based on objective and subjective criteria, including healthcare workers impressions and feelings. This research examines the perception and implications of a 'bad feeling' experienced by healthcare professionals, focusing on its prevalence and characteristics.

METHODS

A cross-sectional paper-based survey was conducted from January to July 2023 at the University Medicine Greifswald and the hospital Sömmerda involving physicians, nurses, medical students and trainees from various specialties. With ethics committee approval, participants were recruited and surveyed at regular clinical events. Data analysis was performed using SPSS® Statistics. The manuscript was written using the Strobe checklist.

RESULTS

Out of 250 questionnaires distributed, 217 were valid for analysis after a 94.9% return rate and subsequent exclusions. Sixty-five per cent of respondents experience the 'bad feeling' occasionally to frequently. There was a significant positive correlation between the frequency of 'bad feeling' and work experience. The predominant cause of this feeling was identified as intuition, reported by 79.8% of participants, with 80% finding it often helpful in their clinical judgement. Notably, in 16.1% of cases, the 'bad feeling' escalated in the further clinical course into an actual emergency. Furthermore, 60% of respondents indicated that this feeling occasionally or often serves as an early indicator of a potential, yet unrecognised, emergency in patient care.

CONCLUSIONS

This study demonstrates the relevance of clinical experience to decision-making. As an expression of this, there is a correlation between the frequency of a 'bad feeling' and the number of years of experience. It is recommended that the 'bad feeling' be deliberately acknowledged and reinforced as an early warning signal for emergency situations, given its significant implications for patient safety. Future initiatives could include advanced training and research, as well as tools such as pocket maps, to better equip healthcare professionals in responding to this intuition.

The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing medical errors in hospital settings: A narrative review

Objectives

This narrative review aimed to explore the impact of checklists and error reporting systems on hospital patient safety and medical errors.

Methods

A systematic search of academic databases from 2013 to 2023 was conducted, and peer-reviewed studies meeting inclusion criteria were assessed for methodological rigor. The review highlights evidence supporting the efficacy of checklists in reducing medication errors, surgical complications, and other adverse events. Error reporting systems foster transparency, encouraging professionals to report incidents and identify systemic vulnerabilities.

Results

Checklists and error reporting systems are interconnected. Interprofessional collaboration is emphasized in checklist implementation. In this review, limitations arise due to the different methodologies used in the articles and potential publication bias. In addition, language restrictions may exclude valuable non-English research. While positive impacts are evident, success depends on organizational culture and resources.

Conclusions

This review contributes to patient safety knowledge by examining the relevant literature, emphasizing the importance of interventions, and calling for further research into their effectiveness across diverse healthcare and cultural settings. Understanding these dynamics is crucial for healthcare providers to optimize patient safety outcomes.

Top 10 Tips on Safety From the Air Medical Transport Industry

The air medical transport industry places a high value on developing and maintaining a culture of safety due to the higher risk nature of its operations. The dynamic nature of response and transport, inherent risks involved with flight, lack of supporting resources, weather conditions, and austere nature of the transport environment are all factors that highlight the need for enhanced safety. As such, the air medical transport industry has developed a robust and unique approach to provider and patient safety involving many tactics not otherwise used in other areas of health care. This article describes some of the unique safety features and approaches that are commonplace in the air medical transport industry and proposes a means for these initiatives to other areas of the health care system.

Dealing with complications in interventional radiology

It is widely accepted that most misadventures, which lead to harm have not occurred because of a single individual but rather due to a failure of process that results in healthcare workers making mistakes. This failure of process and the pervasiveness of adverse events is just as prevalent in Interventional Radiology (IR) as it is in other specialities. The true prevalence and prevailing aetiology of complications in IR are not exactly known as there is a paucity of investigative literature into this area; especially when compared with other more established disciplines such as Surgery. Some IR procedures have a higher risk profile than others. However, published data suggests that many adverse events in IR are preventable (55-84%) and frequently involve a device related complication such as improper usage or malfunction. This article aims to discuss factors that contribute to complications in IR along with tools and strategies for dealing with them to achieve optimal patient outcomes.

Fair Healthcare Practices in Orthopedics Assessed with a New Framework

Background and Objectives: Healthcare systems are supported by the European ideology to develop their egalitarian concerns and to encourage the correct and fair behavior of medical staff. By integrating fair healthcare practices into sustainability, this requirement is addressed. In this research, our objective is to develop and validate, in the current activity of healthcare facilities, a new instrument for evaluating fair healthcare practices as a component of social responsibility integrated into sustainability. Materials and Methods: The research methods consist of deciding the domains of a new framework that integrates fair healthcare practices; the collection of the most recent fair healthcare practices reported by healthcare facilities around the world; elaboration of the contents and evaluation grids of the indicators; the integration of indicators related to fair healthcare practices in the matrix of the new framework for sustainable development; validation of the theoretical model at an orthopedic hospital. Results: The theoretical model of the new framework is composed of five domains: organizational management, provision of sustainable medical care services, economic, environmental, and social. The last domain is developed on the structure of the seven subdomains of the social responsibility standard ISO 26000. The seven indicators that describe fair healthcare practices are attitudes of the profession towards accreditation, effective intervention application, promoting a culture of patient safety, characteristics that affect the effectiveness of transfers, effective healthcare practices, feedback to medical staff, safety checklists. The new reference framework was implemented and validated in practice at an emergency hospital with an orthopedic profile. Conclusions: The practical implementation highlighted the usefulness of the new reference framework, its compatibility, and the possibility of integration with the reference frameworks for the evaluation of European hospitals, with the national legislation for the accreditation of hospitals and outpatient units, as well as with the ISO 9001 standard regarding the implementation of quality management systems. Its added value consists in promoting sustainable development by orienting staff, patients, and interested parties towards sustainability.

Effectiveness of non-interruptive nudge interventions in electronic health records to improve the delivery of care in hospitals: a systematic review

OBJECTIVES

To describe the application of nudges within electronic health records (EHRs) and their effects on inpatient care delivery, and identify design features that support effective decision-making without the use of interruptive alerts.

MATERIALS AND METHODS

We searched Medline, Embase, and PsychInfo (in January 2022) for randomized controlled trials, interrupted time-series and before-after studies reporting effects of nudge interventions embedded in hospital EHRs to improve care. Nudge interventions were identified at full-text review, using a pre-existing classification. Interventions using interruptive alerts were excluded. Risk of bias was assessed using the ROBINS-I tool (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies or the Cochrane Effective Practice and Organization of Care Group methodology for randomized trials. Study results were summarized narratively.

RESULTS

We included 18 studies evaluating 24 EHR nudges. An improvement in care delivery was reported for 79.2% (n = 19; 95% CI, 59.5-90.8) of nudges. Nudges applied were from 5 of 9 possible nudge categories: change choice defaults (n = 9), make information visible (n = 6), change range or composition of options (n = 5), provide reminders (n = 2), and change option-related effort (n = 2). Only one study had a low risk of bias. Nudges targeted ordering of medications, laboratory tests, imaging, and appropriateness of care. Few studies evaluated long-term effects.

DISCUSSION

Nudges in EHRs can improve care delivery. Future work could explore a wider range of nudges and evaluate long-term effects.

CONCLUSION

Nudges can be implemented in EHRs to improve care delivery within current system capabilities; however, as with all digital interventions, careful consideration of the sociotechnical system is crucial to enhance their effectiveness.

Development and evaluation of pharmacist-provided teach-back medication counselling at hospital discharge

BACKGROUND

Pharmacists can use teach-back to improve patients' understanding of medication; however, the evidence of its impact on patient outcomes is inconsistent. From the literature, there is no standardised way to provide pharmacist-delivered medication counselling at hospital discharge, with limited reporting on training.

AIM

To develop a standardised medication counselling procedure using teach-back at hospital discharge, and to evaluate feedback from patients and pharmacists on this initiative.

METHOD

A standardised intervention procedure was developed. Participating pharmacists (n = 9) were trained on teach-back via an online education module and watching a demonstration video created by the researchers. Pharmacists provided patients with discharge medication counselling utilising teach-back and a patient-friendly list of medication changes to take home. To obtain feedback, patients were surveyed within seven days of discharge via telephone and pharmacists answered an anonymous survey online.

RESULTS

Thirty-two patients (mean age: 57 years; range: 19-91) were counselled on a mean 2.94 medications/patient with the mean counselling time as 23.6 min/patient. All patients responded to the survey, whereby 93.7% had increased confidence regarding medication knowledge and were satisfied with the counselling and the information provided. All pharmacist survey respondents (n = 8) agreed they were given adequate training and that teach-back was feasible to apply in practice.

CONCLUSION

This is the first study to evaluate patients' views on pharmacist-provided teach-back medication counselling. With positive patient outcomes, a standardised procedure, and a comprehensive description of the training, this study can inform the development of discharge medication counselling utilising teach-back going forward.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

AVOIDable medical errors in invasive procedures: Facts on the ground - An NHS staff survey

BACKGROUND

Never Events represent a serious problem with a high burden on healthcare providers' facilities. Despite introducing various safety checklists and precautions, many Never Events are reported yearly.

OBJECTIVE

This survey aims to assess awareness and compliance with the safety standards and obtain recommendations from the National Health Service (NHS) staff on preventative measures.

METHODS

An online survey of 45 questions has been conducted directed at NHS staff involved in invasive procedures. The questions were designed to assess the level of awareness, training and education delivered to the staff on patient safety. Moreover, we designed a set of focused questions to assess compliance with the National Safety Standards for Invasive Procedures (NatSSIPs) guidance. Open questions were added to encourage the staff to give practical recommendations on tackling and preventing these incidents. Invitations were sent through social media, and the survey was kept live from 20/11/2021 to 23/04/2022.

RESULTS

Out of 700 invitations sent, 75 completed the survey (10.7%). 96% and 94.67% were familiar with the terms Never Events and near-miss, respectively. However, 52% and 36.49% were aware of National and Local Safety Standards for Invasive procedures (NatSSIPs-LocSSIPs), respectively. 28 (37.33%) had training on preventing medical errors. 48 (64%) believe that training on safety checklists should be delivered during undergraduate education. Fourteen (18.67%) had experiences when the checklists failed to prevent medical errors. 53 (70.67%) have seen the operating list or the consent forms containing abbreviations. Thirty-three (44%) have a failed counting reconciliation algorithm. NHS staff emphasised the importance of multi-level checks, utilisation of specific checklists, patient involvement in the safety checks, adequate staffing, avoidance of staff change in the middle of a procedure and change of list order, and investment in training and education on patient safety.

CONCLUSION

This survey showed a low awareness of some of the principal patient safety aspects and poor compliance with NatSSIPs recommendations. Checklists fail on some occasions to prevent medical errors. Process redesign creating a safe environment, and enhancing a safety culture could be the key. The study presented the recommendations of the staff on preventative measures.

Effective communication and patient safety among nurses in perioperative settings: a best practice implementation project

OBJECTIVES

The aim of this implementation project was to promote evidence-based best practice regarding effective communication and patient safety amongst nurses in perioperative settings.

INTRODUCTION

One of the main causes of surgical errors is inadequate communication. To address this issue, published research has shown that effective communication among healthcare professionals (HCPs) within and between all phases of perioperative care, as well as the proper transfer of all patient information at all transition points, are essential for ensuring patient safety and quality of care.

METHODS

This best practice implementation project was conducted based on the JBI implementation model and included three phases of activity: a baseline audit, a strategies implementation stage and a follow-up audit. The audit criteria used were based on a JBI evidence summary and referred to: education, interdisciplinary team, conflict resolution, team communication, transfer of patient information and safety intraoperative processes. The project was carried out in the perioperative environment of a university hospital, and the sample included 52 nurses.

RESULTS

Eleven audit criteria were used in the baseline audit. For four of these criteria (on education and information transfer) the compliance was zero, for five criteria (on intraoperative processes) the compliance had values between 31 and 66% and for two criteria (on interdisciplinary team/conflict resolution documentation and team communication monitoring), the identified compliance was maximum (100%). Following the identification of four barriers to compliance and the implementation of targeted strategies, the follow-up audit showed complete compliance (100%) for all criteria except three, for which the identified compliance values were 96, 95 and 25%.

CONCLUSION

The implementation of appropriate strategies in this project has led to a significant improvement in nurses' compliance with all audit criteria except one, regarding the verbal transfer of patient information. However, future audits and strategies are needed not only to support the improvements obtained but also to significantly increase the compliance rate for the audit criterion for which only a slight increase in compliance was recorded.

Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews

Background and aim

Improving health care quality and ensuring patient safety is impossible without addressing medical errors that adversely affect patient outcomes. Therefore, it is essential to correctly estimate the incidence rates and implement the most appropriate solutions to control and reduce medical errors. We identified such interventions.

Methods

We conducted a systematic review of systematic reviews by searching four databases (PubMed, Scopus, Ovid Medline, and Embase) until January 2021 to elicit interventions that have the potential to decrease medical errors. Two reviewers independently conducted data extraction and analyses.

Results

Seventysix systematic review papers were included in the study. We identified eight types of interventions based on medical error type classification: overall medical error, medication error, diagnostic error, patients fall, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide. Most studies focused on medication error (66%) and were conducted in hospital settings (74%).

Conclusions

Despite a plethora of suggested interventions, patient safety has not significantly improved. Therefore, policymakers need to focus more on the implementation considerations of selected interventions.

Creation of aNovel Preoperative Imaging Review Acronym to Aid in Revision Endoscopic Sinus Surgery

OBJECTIVES

(1) Identify anatomic contributions to chronic rhinosinusitis (CRS) necessitating revision endoscopic sinus surgery (RESS). (2) Create a clinical acronym to guide imaging review prior to RESS that addresses pertinent sites of disease and potential sites of surgical morbidity.

DATA SOURCES

Ovid MEDLINE, Embase and Medline via Embase.com, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar.

REVIEW METHODS

Systematic search was performed using a combination of standardized terms and keywords. Studies were included if they investigated anatomic contributions to persistent CRS requiring RESS or the relationship between anatomic landmarks and surgical morbidity. Identified studies were screened by title/abstract, followed by full-text review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were strictly followed.

RESULTS

In total, 599 articles met screening criteria, 89 were eligible for full-text review, and 27 studies were included in the final review. The identified anatomic sites of interests are broad; the most frequently cited anatomic region was retained anterior ethmoid cells (22/27 studies), followed by posterior ethmoid cells (14/27 studies). Using the consolidated information, a clinical acronym, REVISIONS, was created: Residual uncinate, Ethmoid cells (agger, Haller, supraorbital), Vessels (anterior and posterior ethmoid), Infundibulum, Septal deviation, I (eye) compartment, Onodi cell, Natural os, and Skull base slope and integrity.

CONCLUSIONS

The REVISIONS acronym was developed as a tool to distill the unique anatomic contributions of primary endoscopic sinus surgery failure into a format that can be easily incorporated in preoperative radiologic review and surgical planning to optimize outcomes and minimize complications.

Impact of the WHO Surgical Safety Checklist Relative to Its Design and Intended Use: A Systematic Review and Meta-Meta-Analysis

BACKGROUND

The aim of this study was to identify what parts of the World Health Organization Surgical Safety Checklist (WHO SSC) are working, what can be done to make it more effective, and to determine if it achieved its intended effect relative to its design and intended use.

STUDY DESIGN

We conducted a qualitative thematic analysis and meta-meta-analyses of findings in WHO SSC systematic reviews following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Twenty systematic reviews were included for qualitative thematic analysis. Narrative information was coded in 4 primary areas with a focus on impact of the WHO SSC. Four themes-Clinical Outcomes, Process Measures, Team Dynamics and Communication, and Safety Culture-pertained directly to the aims or purposes behind the development of the SSC. The other 2 themes-Efficiency and Workload involved in using the checklist and Checklist Impact on Institutional Practices-are associated with SSC use, but were not focal areas considered during its development. Included in the 20 systematic reviews were 24 unique observational cohort studies that reported pre-post data on a total of 18 clinical outcomes. Mortality, morbidity, surgical site infection, pneumonia, unplanned return to the operating room, urinary tract infection, blood loss requiring transfusion, unplanned intubation, and sepsis favored the use of the WHO SSC. Deep vein thrombosis was the only postoperative outcome assessed that did not favor use of the WHO SSC.

CONCLUSIONS

The WHO SSC positively impacts the things it was explicitly designed to address and does not positively impact things it was not explicitly designed for.

Checklist to aid young physicians managing obstetric emergencies in rural India: a quality improvement initiative

Background

The decision to admit or refer a patient presenting with an obstetric emergency is extremely crucial. In rural India, such decisions are usually made by young physicians who are less experienced and often miss relevant data points required for appropriate decision making. In our setting, before the quality improvement (QI) initiative, this information was recorded on loose blank sheets (first information sheets (FIS)) where an initial clinical history, physical examination and investigations were recorded. The mean FIS completeness, at baseline, was 73.95% (1–5 January 2020) with none of the FIS being fully complete. Our objective was to increase the FIS completeness to >90% and to increase the number of FIS that were fully complete over a 9-month period.

Methods

With the help of a prioritisation matrix, the QI team decided to tackle the problem of incomplete FIS. The team then used fishbone analysis and identified that the main causes of incomplete FIS were that the interns did not know what to document and would often forget some data points. Change ideas to improve FIS completeness were implemented using Plan-Do-Study-Act (PDSA) cycles, and ultimately, a checklist (referred to as antenatal care (ANC) checklist) was implemented. The study was divided into six phases, and after every phase, a few FIS were conveniently sampled for completeness.

Results

FIS completeness improved to 86.34% (p<0.001) in the post implementation phase (1 Feb to 31 August 2020), and in this phase, 69.72% of the FIS were documented using the ANC checklist. The data points that saw the maximum improvement were relating to the physical examination.

Conclusion

The use of ANC checklist increased FIS completeness. Interns with no prior clinical and QI experience can effectively lead and participate in QI initiatives. The ANC checklist is a scalable concept across similar healthcare settings in rural India.

Design and Implementation of an Enhanced Recovery After Surgery Protocol in Elective Lumbar Spine Fusion by Posterior Approach: A Retrospective, Comparative Study

STUDY DESIGN

Retrospective, comparative.

OBJECTIVE

The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care.

SUMMARY OF BACKGROUND DATA

Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes.

METHODS

Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals.

RESULTS

A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months).

CONCLUSION

Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3.

Improving quality of care in less than 1 min: a prospective intervention study on postoperative handovers to the ICU/PACU

PURPOSE

Standardisation of the postoperative handover process via checklists, trainings or procedural changes has shown to be effective in reducing information loss. The clinical friction of implementing these measures has received little attention. We developed and evaluated a visual aid (VA) and >1 min in situ training intervention to improve the quality of postoperative handovers to the intensive care unit (ICU) and postoperative care unit.

MATERIALS AND METHODS

The VA was constructed and implemented via a brief (<1 min) training of anaesthesiologic staff during the operation. Ease of implementation was measured by amount of information transferred, handover duration and handover structure. 50 handovers were audio recorded before intervention and 50 after intervention. External validity was evaluated by blinded assessment of the recordings by experienced anaesthesiologists (n=10) on 10-point scales.

RESULTS

The brief intervention resulted in increased information transfer (9.0-14.8 items, t(98)=7.44, p<0.0001, Cohen's d=1.59) and increased handover duration (81.3-192.8 s, t(98)=6.642, p=0.013, Cohen's d=1.33) with no loss in structure (1.60-1.56, t(98)=0.173, p=0.43). Blinded assessment on 10-point scales by experienced anaesthesiologists showed improved overall handover quality from 7.1 to 7.8 (t(98)=1.89, p=0.031, Cohen's d=0.21) and improved completeness of information (t(98)=2.42, p=0.009, Cohen's d=0.28) from 7.3 to 8.3.

CONCLUSIONS

An intervention consisting of a simple VA and <1 min instructions significantly increased overall quality and amount of information transferred during ICU/postanaesthetic care unit handovers.

Safe surgery checklist: evaluation in a neotropical region

OBJECTIVE

assess patient responses and associated factors of items on a safe surgery checklist, and identify use before and after protocol implementation from the records.

METHODS

a cohort study conducted from 2014 to 2016 with 397 individuals in stage I and 257 in stage II, 12 months after implementation, totaling 654 patients. Data were obtained in structured interviews. In parallel, 450 checklist assessments were performed in medical records from public health institutions in the Southwest II Health Region of Goiás state, Brazil.

RESULTS

six items from the checklist were evaluated and all of these exhibited differences (p < 0.000). Of the medical records analyzed, 69.9% contained the checklist in stage I and 96.5% in stage II, with better data completeness. In stage II, after training, the checklist was associated with surgery (OR; 1.38; IC95%: 1.25-1.51; p < 0.000), medium-sized hospital (OR; 1.11; CI95%; 1.0-1.17; p < 0.001), male gender (OR; 1.07; CI95%; 1.0-1.14; p < 0.010), type of surgery (OR; 1.7; CI95%: 1.07-1.14; p < 0.014) and antibiotic prophylaxis 30 to 60 min after incision (OR; 1.10; CI95%: 1.04-1.17; p < 0.000) and 30 to 60 min after surgery (OR; 1.23; CI95%: 1.04-1.45; p = 0.015).

CONCLUSIONS

the implementation strategy of the safe surgery checklist in small and medium-sized healthcare institutions was relevant and associated with better responses based on patient, data availability and completeness of the data.

Clinical Efficacy of Combined Surgical Patient Safety System and the World Health Organization's Checklists in Surgery: A Nonrandomized Clinical Trial

Question

Does patient safety improve when adding the preoperative and postoperative Surgical Patient Safety System checklists to the World Health Organization’s established surgical safety checklist?

Findings

In this stepped-wedge cluster nonrandomized clinical trial with parallel controls that included 9009 surgical procedures, reductions in complications and emergency reoperations occurred when the preoperative Surgical Patient Safety System was added to the surgical safety checklist. The postoperative Surgical Patient Safety System reduced readmissions, whereas overall increased complications were found in the 9678 parallel controls.

Meaning

These findings suggest that joint use of the preoperative and postoperative Surgical Patient Safety System with the intraoperative surgical safety checklist is beneficial for patients.

Importance

Checklists have been shown to improve patient outcomes in surgery. The intraoperatively used World Health Organization surgical safety checklist (WHO SSC) is now mandatory in many countries. The only evidenced checklist to address preoperative and postoperative care is the Surgical Patient Safety System (SURPASS), which has been found to be effective in improving patient outcomes. To date, the WHO SSC and SURPASS have not been studied jointly within the perioperative pathway.

Objective

To investigate the association of combined use of the preoperative and postoperative SURPASS and the WHO SSC in perioperative care with morbidity, mortality, and length of hospital stay.

Design, Setting, and Participants

In a stepped-wedge cluster nonrandomized clinical trial, the preoperative and postoperative SURPASS checklists were implemented in 3 surgical departments (neurosurgery, orthopedics, and gynecology) in a Norwegian tertiary hospital, serving as their own controls. Three surgical units offered additional parallel controls. Data were collected from November 1, 2012, to March 31, 2015, including surgical procedures without any restrictions to patient age. Data were analyzed from September 25, 2018, to March 29, 2019.

Interventions

Individualized preoperative and postoperative SURPASS checklists were added to the intraoperative WHO SSC.

Main Outcomes and Measures

Primary outcomes were in-hospital complications, emergency reoperations, unplanned 30-day readmissions, and 30-day mortality. The secondary outcome was length of hospital stay (LOS).

Results

In total, 9009 procedures (5601 women [62.2%]; mean [SD] patient age, 51.7 [22.2] years) were included, with 5117 intervention procedures (mean [SD] patient age, 51.8 [22.4] years; 2913 women [56.9%]) compared with 3892 controls (mean [SD] patient age, 51.5 [21.8] years; 2688 women [69.1%]). Parallel control units included 9678 procedures (mean [SD] patient age, 57.4 [22.2] years; 4124 women [42.6%]). In addition to the WHO SSC, adjusted analyses showed that adherence to the preoperative SURPASS checklists was associated with reduced complications (odds ratio [OR], 0.70; 95% CI, 0.50-0.98; P = .04) and reoperations (OR, 0.42; 95% CI, 0.23-0.76; P = .004). Adherence to the postoperative SURPASS checklists was associated with decreased readmissions (OR, 0.32; 95% CI, 0.16-0.64; P = .001). No changes were observed in mortality or LOS. In parallel control units, complications increased (OR, 1.09; 95% CI, 1.01-1.17; P = .04), whereas reoperations, readmissions, and mortality remained unchanged.

Conclusions and Relevance

In this nonrandomized clinical trial, adding preoperative and postoperative SURPASS to the WHO SSC was associated with a reduction in the rate of complications, reoperations, and readmissions.

Trial Registration

ClinicalTrials.gov Identifier: NCT01872195

Hospitalization for acute heart failure: the in-hospital care pathway predicts one-year readmission

In patients with heart failure, some organizational and modifiable factors could be prognostic factors. We aimed to assess the association between the in-hospital care pathways during hospitalization for acute heart failure and the risk of readmission. This retrospective study included all elderly patients who were hospitalized for acute heart failure at the Universitary Hospital Lariboisière (Paris) during 2013. We collected the wards attended, length of stay, admission and discharge types, diagnostic procedures, and heart failure discharge treatment. The clinical factors were the specific medical conditions, left ventricular ejection fraction, type of heart failure syndrome, sex, smoking status, and age. Consistent groups of in-hospital care pathways were built using an ascending hierarchical clustering method based on a primary components analysis. The association between the groups and the risk of readmission at 1 month and 1 year (for heart failure or for any cause) were measured via a count data model that was adjusted for clinical factors. This study included 223 patients. Associations between the in-hospital care pathway and the 1 year-readmission status were studied in 207 patients. Five consistent groups were defined: 3 described expected in-hospital care pathways in intensive care units, cardiology and gerontology wards, 1 described deceased patients, and 1 described chaotic pathways. The chaotic pathway strongly increased the risk (p = 0.0054) of 1 year readmission for acute heart failure. The chaotic in-hospital care pathway, occurring in specialized wards, was associated with the risk of readmission. This could promote specific quality improvement actions in these wards. Follow-up research projects should aim to describe the processes causing the generation of chaotic pathways and their consequences.

[The checklists: A help or a hassle?]

Patient safety has become a central component of quality of care. One of the best known and most widely used security tool in all work settings is the checklist. The checklist is a tool that helps to not forget any step during the performance of a procedure, to do tasks with an established order, to control the fulfilment of a series of requirements or to collect data in a systematic way for its subsequent analysis. It is an aid to improve the efficiency of teamwork, promote communication, decrease variability, standardize care and improve patient safety. Main barriers to implementation are reviewed: staff attitudes, hierarchies, poor design, inadequate training, duplication with other work lists, work overload, cultural barriers, lack of replication or checklist closing time. Finally, its applications in Pediatrics are reviewed starting from the most widespread, the safety checklist of pediatric surgery, checklists in neonatal critical units, for safe delivery, for risk procedures, in pediatric intensive care and for pathology time-dependent emergent, e.g. pediatric trauma. It is necessary to highlight the role of leadership in the implantation of a checklist in any area of Pediatrics. There must be one or more people from the team with the support of the Heads of Service and Managers who lead the training of the personnel, direct the implementation of the LV, evaluate the results, inform the rest of the team and can modify the processes depending on the problems found.

Electronic charts do not facilitate the recognition of patient hazards by advanced medical students: A randomized controlled study

Chart review is an important tool to identify patient hazards. Most advanced medical students perform poorly during chart review but can learn how to identify patient hazards context-independently. Many hospitals have implemented electronic health records, which enhance patient safety but also pose challenges. We investigated whether electronic charts impair advanced medical students’ recognition of patient hazards compared with traditional paper charts. Fifth-year medical students were randomized into two equal groups. Both groups attended a lecture on patient hazards and a training session on handling electronic health records. One group reviewed an electronic chart with 12 standardized patient hazards and then reviewed another case in a paper chart; the other group reviewed the charts in reverse order. The two case scenarios (diabetes and gastrointestinal bleeding) were used as the first and second case equally often. After each case, the students were briefed about the patient safety hazards. In total, 78.5% of the students handed in their notes for evaluation. Two blinded raters independently assessed the number of patient hazards addressed in the students’ notes. For the diabetes case, the students identified a median of 4.0 hazards [25%–75% quantiles (Q25–Q75): 2.0–5.5] in the electronic chart and 5.0 hazards (Q25–Q75: 3.0–6.75) in the paper chart (equivalence testing, p = 0.005). For the gastrointestinal bleeding case, the students identified a median of 5.0 hazards (Q25–Q75: 4.0–6.0) in the electronic chart and 5.0 hazards (Q25–Q75: 3.0–6.0) in the paper chart (equivalence testing, p < 0.001). We detected no improvement between the first case [median 5.0 (Q25–Q75: 3.0–6.0)] and second case [median, 5.0 (Q25–Q75: 3.0–6.0); p < 0.001, test for equivalence]. Electronic charts do not seem to facilitate advanced medical students’ recognition of patient hazards during chart review and may impair expertise formation.

Derivation of a procedural performance checklist for ultrasound-guided femoral arterial line placement using the modified Delphi method

BACKGROUND

Many specialties utilize procedural performance checklists as an aid to teach residents and other learners. Procedural checklists ensure that the critical steps of the desired procedure are performed in a specified manner every time. Valid measures of competency are needed to evaluate learners and ensure a standard quality of care. The objective of this study was to employ the modified Delphi method to derive a procedural checklist for use during placement of ultrasound-guided femoral arterial access.

METHODS

A 27-item procedural checklist was provided to 14 experts from three acute care specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback.

RESULTS

Three rounds of the study were performed resulting in a final 23-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist.

CONCLUSION

A procedural performance checklist was created for ultrasound-guided femoral arterial access using the modified Delphi method. This is an objective tool to assist procedural training and competency assessment in a variety of clinical and educational settings.