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PubMed Central
Article . 2019
License: CC BY NC
Data sources: PubMed Central
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Journal of Multidisciplinary Healthcare
Article . 2019 . Peer-reviewed
Data sources: Dove Medical Press
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The surgical ward round checklist: improving patient safety and clinical documentation.

Authors: Krishnamohan,Nitya; Maitra,Ishaan; Shetty,Vinutha D;

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

Abstract

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.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.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%.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.

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Keywords

Medicine (General), R5-920, Journal of Multidisciplinary Healthcare, patient safety, ward round, documentation, Article

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selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
14
Top 10%
Top 10%
Top 10%
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