Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high‐ (HICs) and low‐ and middle‐income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7‐day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.

atient education is important for improving the ability to manage one’s health and optimize clinical outcomes. We identified a paucity in educational materials for patients who undergo a partial foot amputation at our institution and developed an educational brochure to address this deficit as part of a quality improvement initiative. Our aim was to increase the proportion of patients receiving pre- operative education and improve the preparation of vascular surgery patients who will undergo partial foot amputations. We produced an educational brochure to improve patient knowledge and address any preoperative concerns. The effectiveness of this educational material was assessed with a questionnaire in a cohort of patients followed since January 2023. One Plan-Do-Study-Act (PDSA) cycle has been completed thus far. To date, five patients have completed the questionnaire. Three patients provided verbal responses. Sixty-six percent of patients found that the information in the brochure improved their knowledge and that the language of the brochure was easy to understand. Seventy-five percent of patients were confident with caring for their wound in the post-operative period. Educational materials are an important pillar of patient care, particularly in helping to prepare patients for minor amputations where there is a high failure rate and conversion to major amputations. Our brochure was effective in improving patient awareness and knowledge before surgery.

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