Aim Our goal was to audit the quality of the ward round documentation in our Plastic Surgery department by using the SAFE Ward Round Tool of the RCS Edinburgh’s as a reference standard, and to create an in-house pro-forma based on results and discussion. Method An initial cycle based on the SAFE Tool was undertaken with prospective audit of individual daily ward round entries. A sticker pro forma was introduced and re-audit was done using the same criteria. Based on results and discussion, the pro-forma was further improved. Re-audit was performed to assess percentage of completion of its contents. Results The first cycle showed 47% (n = 42) completion rate and re-audit after implementation of the sticker found a rise up to 70% (n = 42). The third cycle examining solely sticker completion yielded a compliance of 88% (n = 61). This improvement reflected to the enthusiastic comments received from staff working in allied specialties. Conclusions Significant lapses in daily ward round documentation were revealed by our methodology. A sticker pro-forma, which we have named the Surgical Tool for the Assessment of Rounds (STAR), was introduced and provided measurable and sustainable improvements on our daily ward round practice. That had as a result the safeguarding of patient safety in the frame of Good Medical Practice. We suggest same methodology to be followed based on the SAFE Ward Round Tool for surgical ward rounds improvement in all the surgical and interventional specialties particularly when there is a component of emergency admission in their daily practice

Aim In October 2020, our hospital moved to an all-online clinical record keeping system, resulting in clinicians becoming responsible for electronically requesting follow up appointments at the time of each clinical encounter. We aimed to ensure that with the introduction of the new computing system, appropriate follow up was booked and all members of staff were proficient in utilising this new system. Method Operative notes were reviewed to obtain the requirements for follow up, specifically for wound assessment clinic (WAC), hand therapy (HT) and outpatient clinic (OPC). Patient charts were then reviewed to ascertain if planned follow up happened, was booked, or was requested. We re-audited this 4 months later, following departmental education. Results In the first week of using the new electronic system, 100% of required WAC (24/24) and HT (13/13) follow up appointments were completed, however 14% (4/27) of required OPC appointments had not been requested. Following departmental education, the re-audit found similar results, however the 12% (4/31) of cases where OPC follow up was not requested, it was not specified in the operation note whether or not this was required. Conclusions When introducing new clinical systems there is potential for unfamiliarity with use to impact on patient care, even after trust-wide training. It is important to bear this in mind and continue to audit and educate staff, implementing appropriate safety netting systems. Detailing the follow up plan in operation notes, including when follow up is not required, improves communication between staff and ensures required follow up is not lost.

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