Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety

March 23, 2016

Source: Surgical Endoscopy [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Answering telephone calls and pagers is common distraction in the operating room. This study sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance.

The study found that distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents’ ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.

Length of publication:  6 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population

February 24, 2016

Source:  International Journal for Quality in Healthcare [Epub ahead of print]

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  Efforts to improve patient safety are challenged by the lack of universally agreed upon terms. The International Classification for Patient Safety (ICPS) was developed by the World Health Organization for this purpose. This study aimed to test the applicability of the ICPS to a surgical population.

The authors conclude that this study demonstrates that a framework for patient safety can be applied to facilitate the organisation and analysis of surgical safety data. Several unique aspects of surgical care require consideration, and by using a standardised framework for describing concepts, research findings can be compared and disseminated across surgical specialties. The codebook is intended for use as a framework for other specialties and institutions.

Length of publication:  Unspecified

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Enhancing surgical safety using digital multimedia technology

November 25, 2015

Source: American Journal of Surgery [Epub ahead of print]

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Date of publication: October 2015

Publication type:  Journal article

In a nutshell: The purpose of this study was to examine whether incorporating digital and video multimedia components improved surgical time-out performance of a surgical safety checklist. A prospective pilot study was designed for implementation of a multimedia time-out, including a patient video. The conclusion of the study was that the multimedia time-out allows improved participation by the surgical team and is preferred to a standard time-out process.

Length of Publication: Unspecified

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Quality improvement in surgery combining lean improvement methods with teamwork training: a controlled before-after study

October 28, 2015

Source:  PLOS ONE 10/9 e0138490

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Date of publication: September 2015

Publication type:  Journal article

In a nutshell:  This study investigated the effectiveness of combining teamwork training and lean process improvement, two distinct approaches to improving surgical safety. A controlled interrupted time series study was conducted in a specialist UK Orthopaedic hospital incorporating a plastic surgery team (which received the intervention) and an Orthopaedic theatre team acting as a control. The study found that combining teamwork training and systems improvement enhanced both technical and non-technical operating team process measures, and were associated with a trend to better safety outcome measures in a controlled study comparison. The authors suggest that approaches which address both system and culture dimensions of safety may prove valuable in reducing risks to patients.

Length of Publication:  1 web page


New safety standards published for invasive procedures

September 30, 2015

Source:  NHS England

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Date of publicationSeptember 2015

Publication type:  News item

In a nutshell: The National Safety Standards for Invasive Procedures (NatSSIPs) aim to reduce the number of patient safety incidents related to invasive procedures in which surgical Never Events could occur. The new standards set out broad principles of safe practice and advise healthcare professionals on how they can implement best practice. The standards will support NHS providers to work with staff to develop and maintain their own, more detailed, local standards and encourage the sharing of best practice between organisations. The NatSSIPs build on the existing WHO Surgical Checklist and promote the effective performance of the Five Steps to Safer Surgery guidance.

Length of Publication:  1 web page


Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients

June 24, 2015

Source:  Annals of Surgery 261/5 pp. 831-8

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Date of publicationMay 2015

Publication type:  Journal article

In a nutshell: This review aims to systematically risk assess and analyse the escalation of care process in surgery to identify problems and provide recommendations for intervention. It discusses Healthcare-Failure-Mode-Effects-Analysis (HFMEA), a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended. Failures in the escalation process amenable to intervention were systematically identified in this review. The authors say that the mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.

Length of Publication:  8 pages


Effectiveness of interventions to improve patient handover in surgery: A systematic review

June 24, 2015

Source:  Surgery 158/1 pp. 85-95

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Date of publication:  May 2015

Publication type:  Journal article

In a nutshell:  The authors of this study examined interventions to improve handover in surgery. The interventions included paper and computerised checklists, forms and standardised operating protocols for handover. All studies found some degree of improvement in handover processes. Checklists or forms can be used to improve information transfer during surgery handovers. The process of implementation is poorly described in the literature however.

Length of Publication:  11 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015

June 24, 2015

Source:  Anaesthesia 70/5 pp. 623-6

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Date of publicationMay 2015

Publication type:  Journal article/Guidelines

In a nutshell: This is a consensus document produced by a Working Party established by the Association of Anaesthetists of Great Britain and Ireland, with representatives from the British Orthopaedic Association and British Geriatric Society. The guideline is presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party analysed recent publications highlighting complications occurring during the peri-operative period. The advice presented is based on previously published advice and clinical studies.

Length of Publication:  4 pages


An immersive “simulation week” enhances clinical performance of incoming surgical interns improved performance persists at 6 months follow-up

May 22, 2015

Source:  Surgery 157/3 pp. 432-43

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Date of publication:  March 2015

Publication type:  Journal article

In a nutshell:  This study aimed to develop, pilot, and evaluate clinical performance after an immersive simulation course for incoming interns. Graduating students were recruited for a 1-week immersive simulation course. Controls received no simulation training. Primary outcome was clinical performance on Objective Structured Clinical Examinations (OSCE) of clinical procedures and surgical technical skills. The immersive simulation course objectively improved subjects’ clinical skills, technical skills, and confidence. Despite similar clinical experience as controls, the intervention group’s improved performance persisted at 6 months follow-up. This intervention could reduce errors and enhance patient safety.

Length of Publication:  12 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


New safety collaborative will improve outcomes for patients with tracheostomies

August 27, 2014

Source:  The Health Foundation

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Date of publication:  July 2014

Publication type:  News item

In a nutshell: A new project in South Manchester will improve the safety and quality of care for patients with tracheostomies. The project, funded by the Health Foundation, aims to improve care and outcomes both in the NHS and around the world. The announcement comes as the European Global Tracheostomy Collaborative (GTC) – a multidisciplinary team of physicians, nurses, allied health clinicians and patients working together to disseminate best practice – is launched during an event at the Royal College of Surgeons in central London, which includes a guest talk from Professor Stephen Hawking. About 15,000 tracheostomies are performed each year in England and Wales. A team at the University Hospital of South Manchester will lead the project and local ‘champions’ in four different sites in Manchester will set targets which can be benchmarked against international hospitals and standards through the GTC’s database.

Length of Publication:  1 web page


Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications

April 30, 2014

Source:  British Journal of Surgery 101/3 pp. 150-8

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Date of publication:  February 2014

Publication type:  Journal article

In a nutshell:   This systematic review evaluated current evidence regarding the effectiveness of the World Health Organization (WHO) surgical safety checklist (SSC) in reducing postoperative complications. A meta‐analysis was conducted to quantify the effect of the WHO SSC on any complication, surgical‐site infection (SSI) and mortality. There was a strong correlation between a significant decrease in postoperative complications and adherence to aspects of care embedded in the checklist. The evidence suggested a reduction in postoperative complications and mortality following implementation of the WHO SSC, but this cannot be regarded as definitive in the absence of high quality studies.

Length of Publication:  9 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.


New recommendations to further improve surgical safety

March 26, 2014

Source:  NHS England

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Date of publication:  February 2014

Publication type:  News item

In a nutshell:  The Surgical Never Events Taskforce has published a report, which makes recommendations for new standards and systems to improve the safety of surgery in hospitals. NHS England has committed to identifying practical ways to take forward the report’s recommendations to eradicate never events from surgical procedures. In the report the taskforce has recommended much greater consistency between different hospitals in all areas of the country. It focuses on standardisation, education and harmonisation. The development and implementation of national standards on the prevention of surgical never events will be key to the taskforce’s recommendations. The full report and summary report can be found on the NHS England website.

Length of Publication:  1 web page