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The surgical ward round checklist: improving patient safety and clinical documentation

Authors Krishnamohan N, Maitra I, Shetty VD

Received 2 July 2018

Accepted for publication 14 January 2019

Published 16 September 2019 Volume 2019:12 Pages 789—794


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 3

Editor who approved publication: Dr Scott Fraser

Nitya Krishnamohan, Ishaan Maitra, Vinutha D Shetty

Department of Upper Gastrointestinal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK

Correspondence: Nitya Krishnamohan
Department of Upper Gastrointestinal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Sharoe Green Lane, Fulwood, Preston PR2 9HT, UK

Purpose: The 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.
Methods: A 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.
Results: Overall 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%.
Conclusion: The 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.

Keywords: ward round, checklist, patient safety, documentation

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