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Found 76 results
  1. News Article
    A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who spoke to PA on condition of anonymity, said: "When I woke up, I felt something in my belly. "The knife they used to cut me broke, and they left a part in my belly." She added: "I was weak, I lost so much blood, I was in pain, all I could do was cry." The object was left inside her for five days, leading to an additional two-week hospital stay. Commenting on the analysis, Rachel Power, chief executive of the Patients Association, said: "Never events are called that because they are serious incidents that are entirely preventable because the hospital or clinic has systems in place to prevent them happening. "When they occur, the serious physical and psychological effects they cause can stay with a patient for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS. "While we fully appreciate the crisis facing the NHS, never events simply should not occur if the preventative measures are implemented." Read full story Source: Sky News, 4 January 2022
  2. Content Article
    Delphi study participants Participants were from the seven regions identified by NHS England. The study revisited several questions from round one to gather further knowledge and understanding of the responses received. The debrief was not undertaken due to all team members not being present, staff wanting to go home, current culture and list overruns. Key initial findings of Delphi study round two The second round facilitated a broader engagement in the literature, as well highlighting a number of reasons why full compliance has not yet been universally achieved. The Delphi study is intended to be an exploratory approach to inform a more in-depth doctoral research study intended to improve patient safety in the operating theatre, inform policy making and quality improvement. Participants felt that training on the checklist should be mandated and take place annually. They also felt that learning from other organisations was key, and that the NHS needs to revise how the checklist is currently being delivered by being more proactive and by providing the foundations of an electronic checklist to all NHS trusts. Participants felt that a lack of direction from senior NHS leaders and multidisciplinary team working may impact on why the checklist is not always completed. With regard to Local Safety Standard for Invasive Procedures (LocSSIPs) and their introduction, participants either strongly agreed or agreed that NHS trusts must be held accountable for ensuring they are implemented. Participants overwhelmingly felt that surgical fires (non-airway) should be classed as a Never Event. To ensure cyclical learning occurs, details of each and every Never Event should be provided to all NHS Trusts Context of the Delphi study The literature to support a greater understanding of the impact on the implementation of checklist is still emerging. The review to date is not intended to be exhaustive, but begins to frame further questions, identify some of the contextual issues and plan for the third and final Delphi round. The use of a Delphi study was born out of curiosity to see to what the theatre safety experts (matrons, managers and clinical educators) think of the current checklist since its introduction across England thirteen years ago. Contextually it can be anticipated that invasive procedures in the NHS and indeed in healthcare globally will continue to rise, in part as a result of the advancement of new supportive technologies, such as robotics and enhanced minimally invasive approaches. Furthermore, access to these treatments is more readily available to different patient groups whose needs and longer-term rehabilitation can be more complex and demanding. While in this regard clinical outcomes, quality of life, and indeed life expectancy can be improved and extended, this is only the case if surgery takes place within optimum conditions. Taking all other factors into consideration, the number of Never Events continues to remain a constant yet stubborn patient safety concern. Future work - Delphi study round three The author is not yet in a position to draw further conclusions as the final Delphi study round is aiming to draw together the results from the first and second rounds, as well as asking further research questions. In acknowledging that the participant rate was 16%, the study cannot claim to know how other Trusts are utilising the SSC. Given the timing and context in which the Delphi study was carried out, it is appreciated that other priorities could have had an impact on trusts' ability and willingness to participate. Nevertheless, it was perhaps surprising to discover over a decade after the initial launch, that there is a lack of direction/leadership and that lack of multidisciplinary team engagement is still an issue. LocSSIPs 2 are due to launch early in 2023 and in order for this to be successful, training must take place, but most importantly NHS England need to hold trusts to account for not introducing them. A long-standing debate around whether surgical (non-airway) fires should be classified as a Never Event was asked to the theatre safety experts, with an overwhelming response agreeing that this type of event should be added to the reportable Never Event list. The study has also raised questions that will be answered in the third Delphi round.
  3. Content Article
    The World Health Organization (WHO) introduced the surgical safety checklist in 2009 after a successful trial in eight pilot countries; the term ‘Never Event’ has been in existence since 2001.[1] NHS England defines a Never Event as; “Serious incidents that are entirely preventable because guidance of safety recommendations providing strong systematic barriers are available at a national level and should have been implemented by all healthcare providers.” The current list of Never Events still only classes three reportable intra-operative ‘Never Events’: wrong site surgery, wrong implant and retained foreign object post-procedure. My question is why only three, what about surgical fires or wrong level spinal surgery? NHS Resolution reported that £13.9 million has been paid out in damages and legal costs for 459 cases relating to clinical negligence caused by surgical burn.[2] That’s an average of £30,000 per claimant. With wrong site surgery there has been a gradual increase in the cases reported. In March 2013, 83 cases were reported and by March 2020 this had increased to 226 cases. Wrong implant is a similar story; in March 2013, 42 cases were reported and by March 2020 this had slightly increased to 47. A positive piece of news is that retained foreign object post-procedure has been on the decline over the same reporting time period. In March 2013, 130 cases were reported and by March 2020, 101 cases were reported. However, there is a financial cost to both the organisation and the NHS as a whole, and a psychological life-long cost to the patient of having to have revision surgery to remove the object. The cost to the NHS between 2015 and 2020 for 389 claims was £12,472,347. That’s an average of £32,000 per claimant. If you add the surgical fires and retained foreign objects costs it totals £26.3 million. In today’s cost of living crisis this would give all NHS workers a good pay rise. Local Safety Standards for Invasive Procedures (LocSSIPs) LocSSIPs was introduced in 2015 and it was anticipated that the mandatory introduction of the WHO surgical safety checklist and the refinement of the three surgical Never Events would lead to a significant reduction in their incidence in NHS England. However, a marked decrease in these Never Events was not seen and, in 2013, NHS England’s Surgical Services Patient Safety Expert Group commissioned a Surgical Never Events Taskforce to examine the reasons for the persistence of these patient safety incidents. The then Director of patient safety, Dr Mike Durkin, in 2015 stated that ”The NatSSIPs do not replace the WHO Safer Surgery Checklist. Rather, they build on it and extend it to more patients undergoing care in our hospitals”. As previously mentioned, it can be argued that the introduction of NatSSIPs/LocSSIPs, and harmonisation with the WHO checklist, to a degree, have been positive as it has led to a slight reduction in two of the three surgical never events in NHS England, but there is still much work to do. As part of my professional role, I undertook an audit across NHS England to ascertain if LocSSIPs were in use in all operating theatres, not other areas of a hospital where invasive procedures may be performed, for example cardiac catheter suite. Seventy-nine NHS England Trusts responded. However, six trusts stated that they had yet to implement LocSSIPs, and they had collectively reported 30 intraoperative ‘Never Events’ that had occurred between 2015 and 2020. There is work currently underway on NatSSIPs 2. There needs to be a real, tangible and credible drive to further reduce patient harm in the operating theatre. Never Events must be published and reported more widely to the public so patients can make a choice and NHS Trusts that have yet to implement LocSSIPs must be held to account. Human factors This brings me on to human factors. As before, an audit was carried out across NHS England. This time 57 responses were received. The largest contributory factor as to why the surgical safety checklist does not get completed was down to culture and the second was staff attitude. Leadership, communication, situational awareness and teamwork were also raised. There was also a clear North/South divide. The majority of the answers from the North of England stated staff attitude as the largest contributory factor and the South of England stated culture. Next steps To conclude, at this stage of my research, there is still much needed improvement and work to undertake. The surgical safety checklist is a credible tool that can lead to no patient harm if used correctly and in combination with LocSSIPs. The new work on LocSSIPs 2 needs to go further to address human factors in the operating theatre. However, a cultural change is needed from the top; time and regular training is needed, similar to the Crew Resource Management that was introduced into the airline industry, as there are similar attitudes present in today’s operating theatres. The NHS should take a leaf out of the aviation industry book and focus on prevention of Never Events by prompting teamwork, communication and managing workload, as opposed to creating a punitive blame culture.[3] The next stages of my PhD research are detailed below. If you would like to hear more on this subject, please come to the Future Surgery Show on the 15 and 16 November 2022 at the Excel Stadium in London and listen to the lecture and my PhD findings to date. References 1. Lembitz A, Clarke TJ. Clarifying "never events" and introducing "always events". Patient  safety in Surgery 2009; 3:26. Accessed 24 July 2022. 2. Keeley L.  Surgical fires must become ‘Never Event’.  Clinical Services Journal 2020:18-20. Accessed 24 July 2022. 3. Reed S, Ganyani R, King R, Pandit M. ‘Does a novel method of delivering the safe surgical checklist improve compliance? A closed loop audit’. International journal of surgery 2016; 32: 99-108. Accessed 24 July 2022.
  4. News Article
    Hardeep Singh, an informatics leader, patient safety advocate and innovator, and friend of the Jewish Healthcare Foundation (JHF), has been awarded the Individual Achievement Award in the 20th John M. Eisenberg Patient Safety and Quality Awards for demonstrating exceptional leadership and scholarship in patient safety and healthcare quality through his substantive lifetime body of work. The Joint Commission and National Quality Forum present Eisenberg Awards annually to recognise major achievements to improve patient safety and healthcare quality. Dr Singh, chief of the Health Policy, Quality & Informatics Program in the Center for Innovations in Quality, Effectiveness and Safety at Michael E. DeBakey VA Medical Center and professor at Baylor College of Medicine, was recognised for his pioneering career in diagnostic and health IT safety and his commitment to translating his research into pragmatic tools, strategies, and innovations for improving patient safety. His commitment to improving patient safety began while pursuing his Master of Public Health at the Medical College of Wisconsin in 2002 when he first learned the field of patient safety existed. That commitment was galvanised early in his medical career, as he found himself treating patients who had been misdiagnosed, received unsafe care, or experienced poor outcomes. The breadth and depth of Dr Singh's research work is remarkable, but what is most notable is the extent to which he has succeeded in translating it into pragmatic strategies and innovations for improving patient safety. Dr. Singh emphasised that while the Eisenberg Award recognizes an individual for their achievements, his work in patient safety has been successful because of its multi-disciplinary and collaborative approach with psychologists, human factors engineers, social scientists, informaticians, patients, and more. That work has led to the development of several tools to improve patient safety, including The Safer Dx Checklist, which helps organizations perform proactive self-assessment on where they stand in terms of diagnostic safety. "As an immigrant and an international medical graduate, I have had a lifelong dream to make an impact on health care. I saw every scientific project as an opportunity to change health care. So, I made a personal commitment that my research must use a pragmatic, real-world improvement lens and challenge the status quo in quality and safety," Dr. Singh said. Read full story Source: Jewish Healthcare Foundation News, 31 August 2022
  5. Content Article
    The article is found on pages 10-12 of the digital edition of the journal.
  6. News Article
    A father whose son took his own life in July 2020 is calling for an "urgent overhaul" of the way some counsellors and therapists assess suicide risk. His son Tom had died a day after being judged "low risk", in a final counselling session, Philip Pirie said. A group of charities has written to the health secretary, saying the use of a checklist-type questionnaire to predict suicide risk is "fundamentally flawed". The government says it is now drawing up a new suicide-prevention strategy. According to the latest official data, 6,211 people in the UK killed themselves in 2020. It is the most common cause of death in 20-34-year-olds. And of the 17 people each day, on average, who kill themselves, five are in touch with mental health services and four of those five are assessed as "low" or "no risk", campaigners say. Tom Pirie, a young teacher from Fulham, west London, had been receiving help for mental-health issues. He had repeatedly told counsellors about his suicidal thoughts - but the day before he had killed himself, a psychotherapist had judged him low risk, his father said. Tom's assessment had been based on "inadequate" questionnaires widely used despite guidelines saying they should not be to predict suicidal behaviour, Philip said. The checklists, which differ depending on the clinicians and NHS trusts involved, typically ask patients questions about their mental health, such as "Do you have suicidal thoughts?" or "Do you have suicidal intentions?" At the end of the session, a score can be generated - placing the individual at low, medium or high risk of suicide, or rating the danger on a scale between 1 and 10. Read full story Source: BBC News, 20 April 2022
  7. Content Article
    ADRe is designed for use by nursing staff (NVQ level 3-5 or above), the professionals closest to patients. By using ADRe complex information on drugs is combined into a checklist providing advice on common problems. This helps nurses recognise and act on adverse drug reaction, including pain, dental pain, aggression, peptic ulcers, and sedation. In doing so, it greatly enhances the administration of medicines, and by capturing this individualised picture of the patients’ health and well-being prompts prescribers to refine dosages. ADRe is very simple to use: Nurses use the Profile to check and record problems that might be related to prescribed medicine. Nurses solve some problems, e.g. dental pain, dehydration, by referrals or paying closer attention to intake. Nurses share the completed ADRe Profile with prescribers (GPs or specialists), who decide prescriptions and doses. Repeating the Profile one month later ensures no new issues have arisen. You can request a copy of the full tool, or even try out part of our digital app by registering.
  8. Content Article
    The campaign poster can be downloaded below and can be printed and displayed at bedsides and on notice boards.
  9. News Article
    A decade after scientists identified a link between certain implants and cancer, the US Food and Drug Administration has ordered “black box” warnings and a new checklist of risks for patients to review. Federal regulators have placed so-called black box warnings on breast implant packaging and told manufacturers to sell the devices only to health providers who review the potential risks with patients before surgery. Both the warnings and a new checklist that advises patients of the risks and side effects state that breast implants have been linked to a cancer of the immune system and to a host of other chronic medical conditions, including autoimmune diseases, joint pain, mental confusion, muscle aches and chronic fatigue. Startlingly, the checklist identifies particular types of patients who are at higher risk for illness after breast implant surgery. The group includes breast cancer patients who have had, or plan to have, chemotherapy or radiation treatments. That represents a large percentage of women who until now were encouraged to have breast reconstruction with implants following their treatment. Reactions to the new requirements were mixed. While some doctors welcomed the new warning system, others worried that the potential risks and side effects would not be conveyed adequately by plastic surgeons who were eager to reassure patients the procedure is safe and that the new checklist would be handled in a dismissive manner. But Dr. Mark Clemens, a professor at M.D. Anderson Cancer Center in Houston who serves a liaison to the F.D.A. for the American Society of Plastic Surgeons Society, said the black box warning and checklist represented “a huge step forward for patient safety and implants.” Read full story Source: The New York Times, 27 October 2021
  10. Content Article
    How to use the checklist Identify a senior leader (e.g., chief quality officer, chief patient safety officer, chief medical officer, or other clinician with oversight of quality) in the organisation who can serve as the champion for learning and exploration of diagnostic excellence. Establish a multidisciplinary team of individuals from various clinical and non-clinical disciplines, including quality and safety, patient representatives, medical educators, and trainees. This team should meet regularly to review and analyse the current state of diagnostic safety and work toward implementation of all 10 checklist items. Complete the checklist as a team or independently. If independent review is preferred, team members should discuss responses and come to consensus on next steps. Develop an action plan that includes clear next steps, metrics of progress, and roles and responsibilities to oversee implementation. The plan needs to be supported by the senior leader champion. Identify regular checkpoints for follow up that include annual review of the checklist and periodic monitoring and revisions to the action plan.
  11. Content Article
    What are the safety challenges of intubation? Intubation is a highly committing procedure. After we induce anaesthesia, our patient stops breathing, and we must rapidly secure the airway and establish ventilation in order to maintain oxygen levels. If oxygen levels drop major organs are rapidly unable to function, in particular the heart, which will stop within minutes. Particularly for our critically ill patients, forward planning and communication are crucial. Anaesthetic drugs and mechanical ventilation are life-saving, but do come at an immediate cost to the overall stability of our patient, who may already be compromised. Environmental and human factors play a huge part in the safety and success of these interventions too, and are arguably easier to optimise beforehand. This involves making clear plans which we share with the whole team, good ergonomics of space and equipment, and just the right number of aide memoirs/checklists to make error harder to occur. It’s also about being aware of your own limitations and surroundings – being mindful of your own level of experience, tiredness, stress, and whether it’s the best time and place to do what you’re about to do. Can you tell us about the intubation safety checklist you developed? As a novice anaesthetist, I became aware that pre-procedure checklists for intubation weren’t always available. My training would emphasise their use, but often it was during highly pressured situations in the farthest corner of the hospital that the checklist was unavailable. The fear of forgetting an essential drug or piece of kit was very real. When, finally, I forgot to prepare a drug to maintain blood pressure during a remote intubation, I resolved to produce a solution for myself and my colleagues. It started with a home-printed sticker, which stuck to the ID card holder. My whole team loved it, so I proceeded to make a plastic card using the DAS emergency intubation guideline checklist. This way, it’s always on your person - avoiding a whole host of potential issues around availability and departmental (dis)agreement on a specific checklist. It seemed a no-brainer, but I’d never have believed there would now be 10,000 cards in circulation worldwide! What feedback have you had from staff who have used it? The feedback has been overwhelmingly positive. And it’s not just a tool for doctors – they’re really popular with Intensive Care and A&E nurses, and operating department practitioners. They can really help bring the team together in a shared mental approach before an intubation, and hopefully help bridge gaps in knowledge too. How can staff get hold of the checklist card? If you’re lucky, you might have grabbed one as a freebie at a DAS conference. A handful were also sent to every trust in the UK in 2019, funded by DAS. If you would like to order a pack of intubation checklist cards for your team, simply complete the attached form. What have you learnt personally in this quality improvement journey? A few things really stand out. Firstly, if you’re passionate about an idea and its potential to improve things, it shouldn’t feel like hard work. Secondly, a concept won’t succeed without the support of your colleagues, but I would caution against asking everybody’s opinion! This sounds controversial, but particularly as a more junior doctor, it can cause awkwardness to not include everybody’s ideas. Be persistent and don’t let your juniority hold you back – you may actually have a sharper eye for cracks in the system, which the familiarity of experience unconsciously bridges. You also need a bit of luck; I’m lucky to have worked in brilliantly supportive departments and to have had a couple of fortuitous introductions. You're now developing a paediatric version, can you tell us a bit more? After the success of the adult checklist card, a lot of people were asking about a version for emergency airway management in kids. I’ve now developed this with the support of my colleagues at The Alex Children’s Hospital in Brighton. Aside from the intubation checklist, I’ve tried to include elements which may not be second nature to paediatric non-specialists in a district general hospital, such as emergency drug dosing and airway kit sizing. Caring for a critically ill baby or child can be unsettling, but I hope this tool provides an extra layer of safety and confidence until definitive paediatric teams take over. You can use the attached form if you would like to order a pack of paediatric checklist cards. Do you have any other ideas up your sleeve for improving patient safety? I have a couple of ideas. I feel the way we store our equipment doesn’t always integrate with our meticulous approach to sick patients, or work well with the limitation of space in hospitals. So I’m working on something…watch this space! Do you have an idea to share with Patient Safety Learning? Have you designed a tool or process that has improved patient safety? Would you like to share your insights with others? Why not sign up to the hub today (for free) and use the 'share' function to tell us more. You can also contact us at content@pslhub.org. By registering for the hub you'll be joining a global network of patients, staff, researchers, managers (and many more) who are passionate about patient safety.
  12. News Article
    A group set-up following the Winterbourne View scandal is urging more people with learning disabilities to attend their annual health check-up. Healthwatch South Gloucestershire said regular health checks could prevent people from dying unnecessarily. It formed after BBC Panorama exposed abuse of patients at Winterbourne View hospital 10 years ago. Only about 36% of people with learning difficulties are believed to have an annual GP health check-up. The Local Democracy Reporting Service (LDRS). said the lack of regular, medical observations contributed to them having a life expectancy of 20 years lower than in the wider population. Healthwatch South Gloucestershire, a regional, independent health and social care champion, has created a checklist to encourage more people to attend appointments to help them improve their life expectancy. Vicky Marriott from the group said: "It is our unrelenting mission to listen and share people's lived experience so that the information informs how health and social care services improve. "We recently listened to people with learning disabilities and their families and developed with them an accessible info-sheet packed full of easy-to-read explanations about the lifesaving benefits of annual health checks." Read full story Source: BBC News, 1 June 2021
  13. Content Article
    On a ward round in 2005 I was about to send home a man who had been successfully treated for pneumonia with intravenous antibiotics. He asked me what was wrong with his left arm. When I looked he had an obvious infection around the intravenous cannula with signs of the infection spreading up the vein. He had been treated with intravenous antibiotics which had been changed to oral 3 days earlier. At that point the cannula should have been removed. It turned out that the infection was caused by MRSA and he required a further 2 weeks of intravenous antibiotics to eradicate the infection. I promised the patient that I would do everything I could to make sure that no one else suffered in the same avoidable way that he had. This led me to think about the process of clinical review on ward rounds. I wondered if we could develop a list of check points that we could routinely go through to protect patients from avoidable harm. During this period, I started to supervise a junior doctor on the team on a ward round and afterwards she said it had been an excellent experience but she did not know if “I had done everything?” This made me think that no one had considered what “Doing everything” was on a ward round. I asked my team to come back 2 days later to discuss what “Doing Everything” was and by the end of that week we had designed our first checklist for ward rounds. The first checklist was a one-sided piece of A4 paper with, as I recall, a table with 15 columns for 15 patients and about 25 rows of points that we thought were essential during a case review. These ranged from items such as organising the notes, filing the results, reading the notes, discussing the case, through to aspects such as does the patient have an intravenous cannula or urinary catheter? Some of the rows were marked in yellow and applied to all patients and others were white, such as the capillary blood glucose which only applied to patients with diabetes. I asked a medical student on our team to watch us working and to tick off the boxes if the appropriate action or an active decision had been considered. I asked that before we moved on to the next patient that the observer highlight any omissions so that these could be corrected. Once the ward round was completed, I kept the checklist forms as well as noting the duration of the ward round. In the early weeks we were surprised to find how much we missed out on ward round reviews. We thought we were very good at hydration and nutrition, spotting cannulas and catheters and making do not attempt cardiopulmonary resuscitation (DNACPR) decisions, but we were not. I found that we were creating a process for clinical review of the patient and a checklist to ensure completion. There were problems. Sometimes the person doing the checking did not call out on omitted items. I can recall one occasion when we had put onto the checklist “Did the consultant read today’s clinical note?” I had forgotten this was now on the checklist until about the fifth patient. I asked the medical student why he had not called me out on this and he said that he was going to tell me at the end of the round! If any team is going to use the checklist process they have to create an atmosphere within the team where it is expected that omissions or errors will be called out. Our work was published in Clinical Medicine.[1] We heard that a whole surgical unit in Melbourne, Australia, picked up on our ward round checklist concept. They similarly found that senior doctors frequently made omissions during ward round processes. They built the checklist into a daily review template. Initially they found that the junior doctors did not complete the checklist. Eventually they found that if the registrars in the team at induction told the junior doctors “This is the way we work here” then they completed the checklist. The checklist then remained in the patient’s notes as evidence of a complete review. For a long time I wanted to find a way to incorporate the checklist into the daily clinical review notes rather than have a separate checklist for the cohort of patients. In 2015 we managed to achieve this by combining the checklist into the daily review template. At Worthing Hospital, Dr Richard Venn and his IT colleagues had pioneered electronic vital signs and nursing assessments. Tim Short[, one of the IT development team, came on one of my ward rounds and saw an opportunity to create a ward round patient review template. One side of this listed the patient’s demographics, clinical problems, vital signs and common blood test results. On the other side was our checklist. I did not want to force teams to use the checklist so this was optional as they created the ward round documentation. We called this process Ward Round Report (WRR). WRR could be run on the desktop computer, laptop, tablet or even smart phone. After the ward round, the sheets could be printed out and filed into the paper notes. With WRR there was plenty of space on side two for adding comments. For example, by this stage there was a question “Did you make any changes in the prescription today? Y/N?” This was the first time in my career that I was regularly making short notes about the reasons for changes in medications – for example, “Ramipril stopped today because systolic blood pressure only 80 mmHg”. What I have learned from this is that there is a process to patient review and being organised and consistent in following this process makes the ward round more effective, efficient and improves patient safety. By being consistent in the process we have released time which can be used for further conversation with the patient or for thinking through complicated cases or for teaching. I have also learned that “safety is no accident”. I like this phrase because of its double meaning that safety is no avoidable harm or accident to the patient and also that safety does not arrive accidentally. Patient safety should be an active process of checking for avoidable errors. With WRR errors still occur but are much less frequent. One point on my ward round form that seems idiosyncratic is asking for something memorable about the patient, such as what is or was their work, or what are their current interests and enjoyments. This creates some personal connection with the patient and certainly helps me to remember all of the patient’s clinical problems. I believe that this personal connection also engenders more commitment to patient safety. If clinical staff take away only one idea from my process, I recommend that it is this: seeking something memorable about each patient. Reference 1. Herring R, Desai T, Caldwell G. Quality and safety at the point of care: how long should a ward round take? Clin Med 2011; DOI: https://doi.org/10.7861/clinmedicine.11-1-20.