A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

Haynes, Alex B.; Weiser, Thomas; Berry, William R.; Lipsitz, Stuart R.; Breizat, Abdel-Hadi S.; Dellinger, E. Patchen; Herbosa, Teodoro; Joseph, Sudhir; Kibatala, Pascience; Lapitan, Marie Carmela; Merry, Alan; Moorthy, Krishna; Reznick, Richard K.; Taylor, Bryce; Gawande, Atul A.

doi:10.1056/nejmsa0810119

Cited by 4,762 publications

(3,272 citation statements)

References 19 publications

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“…Our respondents also included 16 American medical graduates and 13 US citizen IMG’s (16.3 and 13.3% respectively) adding to almost 30% of respondents, and likely provide a healthy comparison to IMG respondents. Residents from General surgery and anesthesia, two specialties noted for their safety efforts, were not part of the study, which could have skewed the results [22,23]. However, we did include residents from obstetrics and gynecology, a specialty believed to have a strong safety culture and found to report the most near- misses on review of English National Reporting and Learning System Data, and did not find any significant difference in reporting [24].…”

Section: Discussionmentioning

confidence: 99%

Assessment of knowledge and attitudes towards safety events reporting among residents in a community health system

Singal

Zafar

Tbakhi

et al. 2018

Journal of Community Hospital Internal Medicine Perspectives

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Background: Resident physicians are known to be infrequent reporters of patient safety events (PSE). Previous studies assessing barriers to resident PSE reporting have not considered possible cultural barriers faced by international medical graduates (IMG). This study aimed to assess the knowledge and attitudes of residents regarding PSE and possible barriers contributing to poor resident reporting.Methods: A cross sectional survey of all house staff undergoing post-graduate residency training at two independent community hospital based academic medical centers was conducted through an online questionnaire. Sample case vignettes were created to assess the residents’ ability to identify safety events and classify them as near miss, adverse events or sentinel events and decide whether they were reportable.Results: The Reporting of PSE increased significantly by year of residency training (p < 0.005), with time taken to file a PSE being the strongest perceived barrier. There was no difference in PSE reporting between IMG’s and non- IMG’s. We identified major knowledge gaps with only 73.9%, 79.6% and 94.3% of respondents correctly identifying sentinel events, adverse events, and near misses, respectively. 58.1% of respondents did not think near misses were reportable.Conclusions: A lack of knowledge is the most important barrier towards PSE reporting. A different cultural background and lack of previous exposure to patient safety report by IMGs is not a significant barrier towards safety event reporting. In the short-term, it appears that focusing limited institutional resources on education rather than acculturation issues would have the greatest benefit.

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Section: Discussionmentioning

confidence: 99%

Assessment of knowledge and attitudes towards safety events reporting among residents in a community health system

Singal

Zafar

Tbakhi

et al. 2018

Journal of Community Hospital Internal Medicine Perspectives

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“…21 Reviewing cases to determine the cause of death is time-consuming but can contribute valuable information for improving the care of future patients. There is increasing evidence that teamwork and communication are key determinants of outcome, [23][24][25][26][27] so it is important to understand not only the contribution of factors related to surgery, anesthesia, and the patient but also the interaction of these factors. Thus, analysis is more likely to be productive if carried out by members of the entire perioperative team rather than by a single craft group.…”

Section: The Central Importance Of Safety In Anesthesiamentioning

confidence: 99%

“…Nevertheless, there is still a need to address ongoing failures in timeliness of certain important aspects of anesthesia practice. A key element of the World Health Organization's (WHO) Surgical Safety Checklist 23 relates to the need to ensure the timely administration of prophylactic antibiotics, when indicated. Timely progression through the steps of an appropriate algorithm is critical to managing unexpected difficulties with patients' airways, but failures to do this still occur regularly.…”

Section: Improving Quality In Health Carementioning

confidence: 99%

An overview of quality and safety in health care

Merry

2012

Can J Anesth/J Can Anesth

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“…The WHO Surgical Safety Checklist was created and implemented to decrease adverse events and increase teamwork amongst groups that can be hierarchical and disempowering to healthcare workers [13,14]. Since implementation, the Surgical Checklist has led to reductions in morbidity and mortality [15], as well as improved adherence to processes of care, teamwork and communication [14,15]. In anesthesia, checklists were able to improve process adherence and capture performance of critical safety elements [16].…”

Section: Introductionmentioning

confidence: 99%

Experience: developing an inpatient malnutrition checklist for children 6 to 59 months to improve WHO protocol adherence and facilitate quality improvement in a low-resource setting

Beck¹,

Mukantaganda

Bayitondere

et al. 2018

Global Health Action

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In low-resource settings, inpatient case fatality for severe acute malnutrition (SAM) remains high despite evidenced-based protocols and resources to treat SAM. Key reasons include a combination of insufficiently trained staff, poor teamwork and inadequate compliance to WHO treatment guidelines which are proven to reduce mortality. Checklists have been used in surgery and obstetrics to ameliorate similarly complicated yet repetitive work processes and may be a key strategy to improving inpatient SAM protocol adherence and reducing unnecessary death. Here, we share our experience developing and piloting an inpatient malnutrition checklist (MLNC) for children 6 to 59 months and associated scoring system to coordinate care delivery, improve team documentation, strengthen WHO malnutrition protocol adherence and facilitate quality improvement in a district hospital in rural Rwanda. MLNC was developed after careful review of the 2009 Rwandan National Nutrition Protocol and 2013 WHO malnutrition guidelines. Critical steps were harmonized, extracted and designed into an initial MLNC with input from pediatric ward nurses, doctors, a locally based pediatrician and a registered dietitian. A scoring system was developed to facilitate quality improvement. Using the standard Plan-Do-Study-Act cycle, MLNC was modified and progress assessed on a monthly to bimonthly basis. Significant modifications occurred in the first 6 months of piloting including incorporation of treatment reminders and formatting improvements, as well as initiation of the MLNC from the emergency department. The MLNC is the first checklist to be developed that unifies WHO 10 steps of treatment of inpatient SAM with local standards. Anecdotally, MLNC was observed to identify gaps in key malnutrition care, promote protocol adherence and facilitate quality improvement. Data gathering on the MLNC local facility impact is underway. Collaborative international efforts are needed to create an inpatient malnutrition checklist for wider use to improve quality and reduce unnecessary, facility-based child mortality.

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A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

Abstract: Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

Cited by 4,762 publications

References 19 publications

Assessment of knowledge and attitudes towards safety events reporting among residents in a community health system

Assessment of knowledge and attitudes towards safety events reporting among residents in a community health system

An overview of quality and safety in health care

Experience: developing an inpatient malnutrition checklist for children 6 to 59 months to improve WHO protocol adherence and facilitate quality improvement in a low-resource setting

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