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Found 108 results
  1. Content Article
    Poor quality ward rounds contribute to a large proportion of patient complications, delayed discharge, and increased hospital cost. This systematic review investigated all interventions aiming to improve patient and process-based outcomes in ward rounds. The review included 84 studies, from 18 countries, in 23 specialties, involving 43 570 patients. It found that checklist interventions significantly reduced ICU length of stay, improved overall documentation, and did not increase ward round duration. Structure interventions did not increase the time spent per patient or impact 30-day readmission rates or patient length of stay.
  2. Content Article
    The Royal College of Surgeons of Edinburgh (RCSEd) have drawn up their top 10 tips for surgical safety using the SEIPS (Safety Engineering Initiative for Patient Safety) model. Click on image to enlarge or download from the attachment below: See also: Safety in surgery series Top 10 priorities for patient safety in surgery Top 10 patient safety tips for surgical trainees
  3. Content Article
    Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. The importance of fall prevention extends beyond patient safety—it reduces hospital liability, enhances patient outcomes and improves overall healthcare efficiency. By proactively assessing and addressing fall risks, healthcare providers can significantly lower the incidence of falls, ensuring a safer environment for patients. Given the aging population and increasing chronic disease burden, fall prevention remains a top priority in improving patient care and quality of life. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. Introduction Falls among patients, particularly in healthcare facilities, remain a pressing concern worldwide. These incidents not only lead to injuries, prolonged hospital stays and increased healthcare costs, but can also have lasting psychological impacts on patients. Preventing patient falls necessitates a multifaceted approach, with fall risk assessment at its core.[1] Understanding the impact of patient falls Patient falls are defined as unintentional descents to the ground that occur in healthcare facilities, including hospitals, nursing homes and rehabilitation centres. According to the World Health Organization (WHO), falls are the second leading cause of unintentional injury deaths globally, with older adults being most at risk.[2] In healthcare facilities, the consequences of falls extend beyond physical injuries; they also affect a patient’s confidence, independence, and quality of life. The financial burden of falls on healthcare systems is substantial. Costs include direct expenses such as treatment for fall-related injuries and indirect costs like litigation, reputation damage and loss of trust. Additionally, healthcare providers experience emotional distress and professional repercussions when preventable falls occur under their watch. Hence, fall prevention is not just a patient safety priority but also an ethical obligation and a cost-saving measure. The role of fall risk assessment Fall risk assessment is a systematic process to identify patients at risk of falling. Healthcare providers can implement targeted interventions to mitigate these risks by evaluating intrinsic and extrinsic factors. Intrinsic factors include age, medical history, mobility impairments and cognitive status, while extrinsic factors encompass environmental hazards, medication side effects and inadequate assistive devices. Risk assessment tools, such as the Morse Fall Scale, Hendrich II Fall Risk Model and STRATIFY Risk Assessment Tool have been widely used. These tools provide a structured approach to assess risk levels and guide preventative measures. However, their effectiveness depends on accurate application and regular updates based on patient conditions. Implementing effective fall risk assessments To maximise the efficacy of fall risk assessments, healthcare facilities must adopt evidence-based strategies and integrate them into their workflows. Key steps include: Standardised assessment protocols: Developing and adhering to standardised protocols ensures consistency in evaluating fall risks across different departments and shifts. Protocols should specify the frequency of assessments, criteria for reassessment and documentation requirements. Staff training: Comprehensive training programme for healthcare workers are essential to enhance their competency in conducting fall risk assessments. Training should cover assessment tools, recognition of risk factors and communication of findings to the care team. Patient and family education: Involving patients and their families in fall prevention efforts fosters a collaborative approach. Educating them about potential risks and preventive measures empowers them to contribute to safety. Technology integration: Advanced technologies such as wearable sensors, predictive analytics and electronic health records (EHRs) can augment traditional fall risk assessments. For instance, sensors can monitor patient movements and alert staff to potential falls, while EHRs can flag high-risk patients for closer observation. Challenges in implementing fall risk assessments Despite its benefits, implementing fall risk assessments is not without challenges. Common barriers include: Resource constraints: Limited staffing, time pressures and inadequate funding can hinder comprehensive risk assessments. Overburdened staff may struggle to prioritise fall prevention alongside other responsibilities. Inconsistent application: Variability in applying risk assessment tools can lead to inaccurate results. Subjective judgment, incomplete data collection and lack of protocol adherence contribute to inconsistencies. Resistance to change: Resistance from staff and administrators to adopt new practices or technologies can impede the integration of fall risk assessments into routine care. Patient non-compliance: Some patients may resist interventions such as bed alarms, mobility aids or supervision, increasing their risk of falling. Strategies to overcome the challenges To address these challenges, healthcare facilities can adopt the following strategies: Leadership support: Strong leadership commitment is crucial to allocating resources, establishing accountability and creating a safety culture. Interdisciplinary collaboration: Engaging multidisciplinary teams, including nurses, physicians, physical therapists and pharmacists, ensures a holistic approach to fall risk assessment and prevention. Continuous Quality Improvement: Regular audits, feedback sessions and performance evaluations help identify gaps in fall prevention efforts and drive improvements. Tailored interventions: Personalising interventions based on individual patient needs and preferences increases their acceptability and effectiveness. Conclusion Preventing patient falls requires a proactive and comprehensive approach, with fall risk assessment as a foundational element. Healthcare facilities can significantly reduce fall-related incidents and their associated consequences by identifying at-risk individuals and implementing tailored interventions. However, the success of fall prevention efforts hinges on overcoming implementation challenges through leadership support, interdisciplinary collaboration and continuous improvement. As healthcare systems evolve, leveraging technology and prioritising patient-centred care will be instrumental in advancing fall risk assessments. By embracing these advancements, healthcare providers can create safer environments that uphold all patients' dignity, independence, and well-being. References The Joint Commission. Fall Reduction Program - Definition and Resources, 28 August 2017 WHO. Falls Factsheet. World Health Organization, 26 April 2021.
  4. Content Article
    Most healthcare organisations (HCOs) find diagnostic errors hard to address. Singh et al. developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error.
  5. Content Article
    This investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic. Reference event Teri had chronic kidney disease and needed regular haemodialysis. He had previously received haemodialysis via a connection between an artery and a vein. However, this connection was failing due to narrowing of the blood vessels and she needed to have a vascular graft implanted so that her treatment could continue. Teri was referred to her local hospital for insertion of a ‘rapid access’ type of vascular graft, to enable her haemodialysis treatment to be carried out as planned. Before Teri’s operation, a consultant vascular surgeon and members of the operating theatre team went to the store cupboard to look at the types of vascular grafts stocked. The consultant vascular surgeon was not sure which size would be needed, so two different sized vascular grafts were selected. However, it was not recognised at the time that they were different types of vascular graft, with one being the intended rapid access type and the other a delayed use graft. Following surgery, the consultant vascular surgeon immediately realised that a delayed use vascular graft had been inserted instead of a rapid access graft. Because the wrong type of vascular graft was inserted, Teri needed to have another surgical procedure and an overnight stay in hospital, which may not have otherwise been needed. Findings The packaging of rapid access and delayed use vascular grafts may be very similar, resulting in an increased risk of staff selecting and inserting the wrong type of graft. The wording used on packaging and labels to describe vascular grafts does not reflect the terminology used by clinicians in the operating theatre. There is Medicines and Healthcare products Regulatory Agency (MHRA) guidance for the labelling and packaging of medicines, but not for medical devices such as vascular grafts. There was a lack of standardisation and therefore variation in how checklists and ‘team briefs’ (procedures that aim to ensure patient safety) were completed/ conducted and recorded in different operating theatres. The incorporation of national safety standards alone may not be successful without an embedded safety culture being in place. Barcode scanning technology (Scan4Safety) can be used to mitigate the risk of an incorrect medical device being selected/inserted. Due to the reduced central management of the Scan4Safety programme, trusts have been developing applications and using adaptations of the scanning technology, resulting in inconsistent use and variable effectiveness. Safety recommendations HSIB made four safety recommendations as a result of this investigation. HSIB recommends that NHS England reviews system requirements for barcode scanning technology, in order to support local organisations to reduce the risk of incorrect selection and insertion of prostheses/implants. HSIB recommends that the British Standards Institution updates the applicable standard/s, and raises with the International Organization for Standardization, to state that medical device labelling and packaging should detail the specific use of an item. This should be developed with user input to drive consistency in the terminology used on medical device labelling/packaging. HSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures the assurance processes for designated approved bodies (to check medical device manufacturers conform to packaging standards) are amended to consider context of use and usability guidelines, to reduce the risk of selecting and inserting the incorrect device. HSIB recommends that the Medicines and Healthcare products Regulatory Agency publishes guidance on the labelling and packaging of medical devices, to promote best practice and reduce selection of the incorrect item. Safety observations HSIB makes the following safety observations: It may be beneficial if the term ‘user’ in the context of medical devices was defined in international and national standards to incorporate all staff who interact with the device, including those who select the device, check it before use and use it. It may be beneficial for healthcare organisations to deliver multi-disciplinary team training on the key principles of the revised ‘National safety standards for invasive procedures’ to support the implementation and embedding of these standards. It may be beneficial for trusts to assign experienced operating theatre clinicians to lead on the implementation of the ‘National safety standards for invasive procedures’, to address the cultural issues hindering implementation. Related resources on the hub: NatSSIP2 sequential steps: The NatSSIPs Eight – Flow chart Error traps gallery
  6. Content Article
    The PIT stop (prosthesis/implant timeout) checklist is Birmingham Women's and Children's NHS Trust's visual and aid memoir. It was launched to limit 'human error' and thus preventing never events (wrong implant/prosthesis). The four steps cover the intra-operative stages when implants are required. It works by recording what is requested on a small, hand held white board, and works in harness with the NatSSIPs 8, specifically step 5 of the infographic that has been previously developed. Download the checklist in Word from the attachment below:
  7. Content Article
    This paper from Roberts et al. examines the application of the Surgical Safety Checklist (SSC) within NHS hospital operating theatres England. The aim of the study, through a combination of open-ended questions, was to solicit specific information including views and opinions from operating theatre experts to establish from how the World Health Organisations (WHO) SSC is being applied, and therefore and why intraoperative ‘Never Events’ continue to occur more than a decade after the SSC was introduced. Participants were from the seven regions identified by NHS England. The intention of this paper is not to establish definitively whether the quantitatively identified themes; including a lack of training and engagement with human factors explains the increased presence of intraoperative ‘Never Events’. However, these themes, when subjected to methodological triangulation with the current literature, do appear consistent, and therefore provide an exploratory approach to inform research intended to improve safety in the operating theatre by informing policy and its application to safe practice ultimately towards quality improvements.
  8. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Gordon talks to us about how bureaucracy in the health service can compromise patient safety, the vital importance of agreed quality standards and what hillwalking has taught him about healthcare safety.
  9. Content Article
    Commercial aviation practices, including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists, have direct applicability to anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. In this editorial, Jelacic et al. discuss how these commercial aviation practices may be applied in the operating room.
  10. Content Article
    Watch this World Patient Safety Day webinar with Nigel Roberts on enhancing patient safety and surgical outcomes with the surgical safety checklist.
  11. Content Article
    Dr Kristin Harris, Research Fellow in the Department of Anaesthesia and Critical Care at Haukeland University Hospital, Bergen, Norway, discusses why patient safety patient involvement personally matters to her and talks about the tool she's currently working on, which are safety checklists specific to surgical patients.
  12. Content Article
    This checklist has been developed by the Alzheimer’s Society to allow patients to check symptoms that could be a possible sign of dementia. Endorsed by the Royal College of General Practitioners (RCGP), it is a simple tool to help patients and their families clearly communicate their symptoms and concerns to a GP or other healthcare professional. It is not a diagnostic tool, but aims to provide a basis for helpful conversations.
  13. Content Article
    Standard operating procedures (SOPs) should improve safety in the operating theatre, but controlled studies evaluating the effect of staff-led implementation are needed. Morgan et al. evaluated three team process measures (compliance with WHO surgical safety checklist, non-technical skills and technical performance) and three clinical outcome measures (length of hospital stay, complications and readmissions) before and after a 3-month staff-led development of SOPs.  They found that SOPs when developed and introduced by frontline staff do not necessarily improve operative processes or outcomes. The inherent tension in improvement work between giving staff ownership of improvement and maintaining control of direction needs to be managed, to ensure staff are engaged but invest energy in appropriate change.
  14. Content Article
    According to the World Health Organization, humanity faces its greatest ever threat: the climate and ecological crisis. Healthcare services globally have a large carbon footprint, accounting for 4-5% of total carbon emissions. Surgery is particularly carbon intensive, with a typical single operation estimated to generate between 150-170kgCO2e, equivalent to driving 450 miles in an average petrol car. The UK and Ireland surgical colleges have recognised that it is imperative for us to act collectively and urgently to address this issue. The Royal College of Surgeons of Edinburgh have collated a compendium of peer-reviewed evidence, guidelines and policies that inform the interventions included in the Intercollegiate Green Theatre Checklist. This compendium should support members of the surgical team to introduce changes in their own operating departments. The recommendations apply the principles of sustainable quality improvement in healthcare, which aim to achieve the “triple bottom line” of environmental, social and economic impacts.  How to use the checklist The checklist is divided into four sections, the first dedicated to anaesthetic care, and the subsequent three looking at preparation for surgery, intra-operative practice and post-operative measures. It is suggested the checklist is initially used at the daily brief at the start of an operating list, as an aide-memoire for the team of the modifications that could be applied there and then. Once these practices become embedded into practice, then the checklist may be used less frequently. At present, some theatres will lack the infrastructure required to enact all the suggested interventions and so the checklist can serve as a roadmap for discussion with management, or at departmental meetings, to guide required changes. Finally, if completed regularly, the checklist could also be used as a scorecard to monitor progress.
  15. Content Article
    Traditional approaches to patient safety and handoffs need redesigning to acknowledge the different constraints, goals, and requirements necessary for each individual patient. There is no “one size fits all” approach to patient safety, handoffs or a perfect checklist. Despite the inherit complexity present in healthcare systems, we tend to reduce our thinking about handoffs into simple solutions of checklists and cognitive aids. In studies of these tools, their association with patient outcomes is unclear with mixed results in large studies. Incorporating general resilience engineering principles of visibility, understanding, anticipation, and learning provides new opportunities for increased patient safety. This involves situating the handoff in the context of the system - understanding the process of summarising pre-handoff and of developing understanding post-handoff, tracing flows of information and patients, and considering the role of feedback and control loops in the system. Direct observations, analysis of multiple outcomes, focus on patient evolving specific exceptions, reducing the number of handoffs, taking time for two-way discussions, and user-centred design and redesign may promote acceptability and sustainability of a new view of handoffs for improved patient safety.
  16. Content Article
    This NatSSIPs 8 flow chart illustrates the sequential standards in the National Safety Standards for Invasive Procedures 2 combined with the World Health Organization (WHO) surgical safety checklist. The National Safety Standards for Invasive Procedures 2 (NatSSIPs 2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. They consist to two inter-related sets of standards: Organisational standards – clear expectations of what Trusts and external bodies should do to support teams to deliver safe invasive care. Sequential standards – the procedural steps that should be taken where appropriate by individuals and teams, for every patient undergoing an invasive procedure. The NatSSIPs 8 flow chart below combines the NatSSIPs sequential standards with the WHO Surgical Safety Checklist to provide a simple visual reminder tool for health and care staff. Its author is Nigel Roberts, Head Theatre Practitioner (Head of Nursing) at Birmingham Women’s and Children’s NHS Foundation Trust, and the flow chart was produced with support from Patient Safety Learning and Dr Annie Hunningher. Are you a healthcare professional interested in learning more about NatSSIPs? On the hub we host the National NatSSIPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSSIPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email [email protected].
  17. News Article
    Early warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020
  18. Content Article
    The OneTogether Quality Improvement Resources are intended to provide practical information for implementing best practice for each of the elements of care across the surgical pathway. These resources can be used as stand‑alone documents, but are recommended to be used in conjunction with the OneTogether Assessment Toolkit. The OneTogether Assessment Toolkit is designed to measure adherence to best practice to prevent surgical site infection (SSI). Following completion of the OneTogether Assessment, healthcare professionals will be able to identify areas of low compliance and develop a prioritised action plan for improvement. The Quality Improvement Resources summarise the evidence underpinning recommended practice and provide a competency assessment checklist. The information they contain is drawn from evidence-based guidelines or expert recommendations from professional bodies
  19. Content Article
    The Patient Safety Database (PSD), previously called Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. They have begun by developing an open and anonymous incident reporting system focused on non-technical skills. Each quarter they summarise in their newsletter cases reported on the platform. Read the latest newsletter.
  20. Content Article
    Confronted with worldwide evidence of substantial public health harm due to inadequate patient safety, the World Health Assembly (WHA) in 2002 adopted a resolution (WHA55.18) urging countries to strengthen the safety of health care and monitoring systems. The resolution also requested that WHO take a lead in setting global norms and standards and supporting country efforts in preparing patient safety policies and practices. In May 2004, the WHA approved the creation of an international alliance to improve patient safety globally; WHO Patient Safety was launched the following October. For the first time, heads of agencies, policy-makers and patient groups from around the world came together to advance attainment of the goal of “First, do no harm” and to reduce the adverse consequences of unsafe health care. The purpose of WHO Patient Safety is to facilitate patient safety policy and practice. It is concentrating its actions on focused safety campaigns called Global Patient Safety Challenges, coordinating Patients for Patient Safety, developing a standard taxonomy, designing tools for research policy and assessment, identifying solutions for patient safety, and developing reporting and learning initiatives aimed at producing ‘best practice’ guidelines. Together these efforts could save millions of lives by improving basic health care and halting the diversion of resources from other productive uses.
  21. Content Article
    In April 2009 a 'considerative checklist' was developed to ensure that all important aspects of care on a team's routine and post-take general internal medicine ward rounds had been addressed and in order to answer the question: How long should a ward round take, when conducted to high standards of quality and safety at the point of care? The checklist has been used on 120 ward rounds: 90 routine ward rounds and 30 post-take ward rounds. Overall, the average time per patient was 12 minutes (10 minutes on routine rounds and 14 minutes on post-take rounds). The considerative checklist has encouraged and enabled documented evidence of high quality and safe medical care, and anecdotally improved team working, communication with patients, and team and patient satisfaction.
  22. Content Article
    Dr Gordon Caldwell believes that patient safety should be an active process of checking for avoidable errors. In this blog for the hub, he describes how he developed a checklist for his ward rounds and how this became incorporated into the daily clinical review notes to ensure that all the important aspects of care on a team’s routine ward rounds are actively addressed. 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.
  23. Content Article
    Previous research suggests that surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality as well as improvement in teamwork and communication. These findings stem from evaluations of individual or small groups of hospitals. Studies with more hospitals have assessed the relationship of checklists with teamwork at a single point in time. The objective of this study from Molina et al. was to evaluate the impact of a large-scale implementation of SSCs on staff perceptions of perioperative safety in the operating room. They concluded that a large-scale initiative to implement SSCs is associated with improved staff perceptions of mutual respect, clinical leadership, assertiveness on behalf of safety, team coordination and communication, safe practice, and perceived checklist outcomes.
  24. Content Article
     This Joint Committee International handbook offers checklists for healthcare staff to keep themselves safe from chemical and physical hazards, infectious agents, workplace violence, ergonomic problems, work-related stress, and more. The book also includes managers’ checklists to ensure that the right administrative controls and processes are in place to safeguard health care staff. All checklists are based on authoritative, evidence-based sources that have proven valuable. All the checklists are straightforward and easy to use and understand and cover the key areas of risk for health care workers. Each section of checklists is introduced by compelling statistics that show how dangerous working in the healthcare environment can be, without proper precautions. The checklists provide the procedures or must-do activities to ensure that health care workers are as safe as can be.
  25. Content Article
    The prevalence of facility-based childbirth in low-resource settings has increased dramatically during the past two decades, yet gaps in the quality of care persist and mortality remains high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes. This study, published in The New England Journal of Medicine, found that birth attendants’ adherence to essential birth practices was higher in facilities that used the coaching-based WHO Safe Childbirth Checklist program than in those that did not, but maternal and perinatal mortality and maternal morbidity did not differ significantly between the two groups.
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