As evidenced by the WHO safe surgery initiative, checklist use improves the safety of patients undergoing surgery. Developing on this concept we have designed and implemented an easy to use sticker based checklist which is completed during ward rounds. The checklist is then incorporated in to the patients written medical record. The checklist has improved ward round structure, planning, team handovers and adherence to the Health Service Executive (HSE) Records Management standards without increasing the work load of surgical team.
NAME WARD BED
Neurosurgical Team DATE / /10 TIME : Cons/SpR/Reg/SHO/Intern
NAME WARD BED
Professor Hill’s Team DATE / /10 TIME : Cons/SpR/Reg/SHO/Intern
xxxx xxxxx #172 Intern xxxxx xxxx #171 Intern
MCN: xxxxxx MCN: xxxxxx
A Surgical Ward Round Checklist;
The design, development and implementation of an innovative tool to improve patient safety.
H Ali1, R KJ Murphy2, Z Burukan2, P Dhillon2,
M Corrigan1,2, A Sheikh2, A Hill1,2,
1. Royal College of Surgeons in Ireland, Dublin, Ireland
2. Department of Surgery, Beaumont Hospital and RCSI, Dublin,
Incomplete hospital documentation is potentially dangerous to patient care.The WHO safe surgery checklist initiative improves the safety of patients undergoing surgery.
This study aimed to:
1. To demonstrate the need for structured ward round reporting.
2. To design a sticker based checklist tool which is completed during ward rounds.
3. To evaluate this tool in practice.
Written questionnaires were employed to gauge the opinions of surgical teams. A checklist was then developed utilising surgical focus groups. Implementation of the checklist was assessed following education with prospective evaluation of ward note taking comparing a study group of 15 patients, with a control group of 47 patients.
Eighty one per cent (38) of the 47 doctors surveyed believed that ward rounds could be improved. Prior to implementation of the checklist no medical notes were in compliance. Poorly documented variables included vitals 27% , abnormal lab tests 15% , management plan 60% and medical council numbers 7%. Post implementation 100% (15) of the charts utilising the checklist were in compliance compared with none in the control group (47).
The sticker checklist resulted in marked subjective and objective improvement in the structure and documentation of ward rounds. It is easy to use, provides guidance for inexperienced doctors and by improving documentation and handovers is valid and relevant to improving patient safety.