<p>The surgical ward round checklist: improving patient safety and clinical documentation</p>

Abstract

PurposeThe daily surgical ward round (WR) is a complex process. Key aspects of patient assessment can be missed or not be documented in case notes. Safety checklists used outside of medicine help standardize performance and minimize errors. Its implementation has been beneficial in the National Health Service. A structured WR checklist standardizes key aspects of care that need to be addressed on a daily surgical WR. To improve patient safety and documentation, we implemented a surgical WR checklist for daily surgical WRs at our hospital. We describe our experience of its implementation within the general surgical department of a teaching hospital in the UK.MethodsA retrospective review of case note entries from surgical WRs (including Urology and Vascular surgery) was conducted between April 2015 and January 2016. WR entries of 72 case notes were audited for documentation of six parameters from the surgical WR checklist. A WR checklist label with the parameters was designed for use for each WR entry. A post-checklist implementation audit of 61 case notes was performed between Jan 2016 and August 2016. To assess outcome on patient safety, adverse events relating to these six parameters reported to the local clinical governance team were reviewed pre – and post-checklist implementation.ResultsOverall documentation of the six parameters improved following implementation of the WR checklist (pre-checklist=26% vs post-checklist=79%). Documentation of assessment of fluid balance improved from 8% to 76%. Subsequent audit at 3 months post-checklist implementation maintained improvement with documentation at 72%.ConclusionThe introduction of the surgical WR checklist has improved documentation of key aspects of patient care. The WR checklist benefits patient safety. It improves communication, documentation and ensures that key issues are not missed at patient assessment on WRs. A crucial factor for successful documentation is engagement by the senior clinicians and nursing staff on its benefits which ensures appropriate use of WR checklist labels occurs as doctors rotate through the surgical placement.

Teamwork in a Surgical Department

“…The surgical ward team consists of at least one surgeon and one nurse. The team is led by a surgical consultant or a surgical registrar [33]. The surgical registrar must have the guaranteed possibility to consult the chief surgeon for pending questions.…”

“…This team conducts the daily ward round of the patients in the surgical ward and takes care of the resulting ward work. The surgical ward round is a complex process [33]. Sometimes it lasts several hours until all parameters in every patient case are assessed completely [33].…”

“…The surgical ward round is a complex process [33]. Sometimes it lasts several hours until all parameters in every patient case are assessed completely [33]. It is advantageous if the individual members of the surgical ward team do not change too often, e.g.…”

“…Filling this large gap in science will show at which points in the surgical ward improvements in teamwork are necessary. In 2019, Krishnamohan introduced a surgical ward round checklist to monitor documentation [33]. It is claimed to improve communication between team members in the surgical ward team [33].…”

“…In 2019, Krishnamohan introduced a surgical ward round checklist to monitor documentation [33]. It is claimed to improve communication between team members in the surgical ward team [33]. In 2014, Hull introduced a combined assessment toolkit for technical and nontechnical team skills in surgical ward care [70].…”