Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics? - can the checklist help? Supporting evidence from analysis of a national patient incident reporting system

Panesar, Sukhmeet S.; Noble, Douglas; Mirza, Saqeb B.; Patel, Bhavesh; Mann, Bhupinder; Emerton, Mark; Cleary, Kevin; Sheikh, Aziz; Bhandari, Mohit

doi:10.1186/1749-799x-6-18

Cited by 65 publications

(66 citation statements)

References 23 publications

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“…Then, it is performed the confirmation of the patient, location, procedure and correct positioning, surgical site, prophylaxis of venous thromboembolism, presence of the diagnostic image, confirmation of sterilization of equipment and anticipation of any critical steps (WHO, 2009;PANESAR et al, 2011).…”

Section: Discussionmentioning

confidence: 99%

Surgical patient safety in a public teaching hospital

Calegari¹,

Oliveira²,

Silva³

et al. 2018

Biosci. J.

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Section: Discussionmentioning

confidence: 99%

Surgical patient safety in a public teaching hospital

Calegari¹,

Oliveira²,

Silva³

et al. 2018

Biosci. J.

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“…70,406,551,552 Empirical research supports assertions that the WHOSSC (i) saves lives; [553][554][555][556][557] (ii) improves communication across the surgical team; 558 (iii) reduces the occurrence of wrong-site surgery; 63 (iv) promotes adherence to defined antibiotic protocols, thereby reducing the incidence of surgical-site infection; [559][560][561] and (v) fosters more efficient use of theatre time and resources, 556 while supporting appropriate staffing levels. 439 Despite such obvious benefits, operationalisation of the WHOSSC may be poor.…”

Section: Reducing Surgical Complicationsmentioning

confidence: 98%

“…[57][58][59][60][61][62] So, too, do those that arise as a consequence of surgery. 63,64 A more hidden cause is, quite simply, incorrect diagnosis. [65][66][67][68][69] In addition, there is variation in the delivery of medical and nursing care.…”

Section: Overviewmentioning

confidence: 99%

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Herepath

Kitchener

Waring

2015

Health Serv Deliv Res

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BackgroundHospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.ObjectivesThis study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.DesignWe used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.SettingWelsh Government and NHS Wales.ParticipantsInterviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.Main outcome measuresIdentification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.ResultsAn innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.ConclusionsHeightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…A change in planned procedure, owing to list order change or intraoperative complication, particularly when a different IOL model or power had to be selected, was implicated in a number of incidents (16). Changes in staff members during the list, often with consequent breakdown in communication, were detailed in some reports as contributing factors.…”

Section: Change In Planned Procedures or Change In Team Members Duringmentioning

confidence: 99%

“…The true incidence of wrong IOL implantation is unknown as incident reporting systems do not necessarily provide an accurate assessment of the epidemiology of medical errors 15,16 and mandatory reporting of incidents since 2010 alongside a better reporting culture may explain the apparent higher rate in the later data.…”

Section: Data Comparisonsmentioning

confidence: 99%

Wrong intraocular lens events—what lessons have we learned? A review of incidents reported to the National Reporting and Learning System: 2010–2014 versus 2003–2010

Steeples

Hingorani

Flanagan

et al. 2016

Eye

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Purpose To identify the causal factors in wrong intraocular lens (IOL) events from a national data set and to compare with similar historical data (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010) prior to mandatory checklist use, for the purpose of developing strategies to prevent never events. Methods Data from wrong IOL patient safety incidents (PSIs) submitted to the National Reporting and Learning System (2010)(2011)(2012)(2013)(2014) were reviewed by thematic analysis and compared with the data previously collected by the group using the same methodology. Results One hundred and seventy eight wrong IOL PSIs were identified. The contributory factors included: transcription errors (n = 26); wrong patient biometry (n = 21); wrong IOL selection (n = 16); changes in planned procedure (n = 16); incorrect IOL brought into theatre (n = 11); left/right eye selection errors (n = 9); communication errors (n = 9); and positive/negative IOL power errors (n = 9). In 44 PSIs, no causal factor was reported, limiting the learning value of such reports. Compared with the data from previous years, biometry errors were much reduced but IOL transcription and documentation errors were greater, particularly if further checks did not refer to the original source documentation. IOL exchange surgery was reported in 45 cases. Conclusions The selection and implantation of the correct IOL is a complex process which is not adequately addressed by existing checking procedures. Despite the introduction of surgical checklists, wrong IOL incidents continue to occur and are probably underreported. Human or behavioural factors are heavily implicated in these errors and need to be addressed by novel approaches, including simulation training. There is also scope to further improve the quality and detail of incident reporting and analysis to enhance patient safety.

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Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics? - can the checklist help? Supporting evidence from analysis of a national patient incident reporting system

Cited by 65 publications

References 23 publications

Surgical patient safety in a public teaching hospital

Surgical patient safety in a public teaching hospital

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Wrong intraocular lens events—what lessons have we learned? A review of incidents reported to the National Reporting and Learning System: 2010–2014 versus 2003–2010

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