Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review.

BACKGROUND: Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries. METHODS: We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews. RESULTS: Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified. CONCLUSIONS: Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.

Patterns in neurosurgical adverse events and proposed strategies for reduction.

Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to reducing risk and to measuring and improving outcomes. The authors performed a review of patterns and frequencies of adverse events in neurosurgery as background for future efforts directed at the improvement of quality and safety in neurosurgery. They found 6 categories of contributory factors in neurosurgical adverse events, categorizing the events as influenced by issues in surgical technique, perioperative medical management, use of and adherence to protocols, preoperative optimization, technology, and communication. There was a wide distribution of reported occurrence rates for many of the adverse events, in part due to the absence of definitive literature in this area and to the lack of standardized reporting systems. On the basis of their analysis, the authors identified 5 priority recommendations for improving outcomes for neurosurgical patients at a population level: 1) development and implementation of a national registry for outcome data and monitoring; 2) full integration of the WHO Surgical Safety Checklist into the operating room workflow, which improves fundamental aspects of surgical care such as adherence to antibiotic protocols and communication within surgical teams; and 3-5) activity by neurosurgical societies to drive increased standardization for the safety of specialized equipment used by neurosurgeons (3), more widespread regionalization and/or subspecialization (4), and establishment of data-driven guidelines and protocols (5). The fraction of adverse events that might be avoided if proposed strategies to improve practice and decrease variability are fully adopted remains to be determined. The authors hope that this consolidation of what is currently known and practiced in neurosurgery, the application of relevant advances in other fields, and attention to proposed strategies will serve as a basis for informed and concerted efforts to improve outcomes and patient safety in neurosurgery.

Perspectives in quality: designing the WHO Surgical Safety Checklist.

The World Health Organization's Patient Safety Programme created an initiative to improve the safety of surgery around the world. In order to accomplish this goal the programme team developed a checklist with items that could and, if at all possible, should be practised in all settings where surgery takes place. There is little guidance in the literature regarding methods for creating a medical checklist. The airline industry, however, has more than 70 years of experience in developing and using checklists. The authors of the WHO Surgical Safety Checklist drew lessons from the aviation experience to create a safety tool that supports essential clinical practice. In order to inform the methodology for development of future checklists in health care, we review how we applied lessons learned from the aviation experience in checklist development to the development of the Surgical Safety Checklist and also discuss the differences that exist between aviation and medicine that impact the use of checklists in health care.

Evaluating an Intervention to Improve Communication Between Oncology Clinicians and Patients With Life-Limiting Cancer: A Cluster Randomized Clinical Trial of the Serious Illness Care Program.

IMPORTANCE: Earlier clinician-patient conversations about patients' values, goals, and preferences in serious illness (ie, serious illness conversations) are associated with better outcomes but occur inconsistently in cancer care. OBJECTIVE: To evaluate the efficacy of a communication quality-improvement intervention in improving the occurrence, timing, quality, and accessibility of documented serious illness conversations between oncology clinicians and patients with advanced cancer. DESIGN, SETTING, PARTICIPANTS: This cluster randomized clinical trial in outpatient oncology was conducted at the Dana-Farber Cancer Institute and included physicians, advanced-practice clinicians, and patients with cancer who were at high risk of death. MAIN OUTCOMES AND MEASURES: The primary outcomes (goal-concordant care and peacefulness at the end of life) are published elsewhere. Secondary outcomes are reported herein, including (1) documentation of at least 1 serious illness conversation before death, (2) timing of the initial conversation before death, (3) quality of conversations, and (4) their accessibility in the electronic medical record (EMR). RESULTS: We enrolled 91 clinicians (48 intervention, 43 control) and 278 patients (134 intervention, 144 control). Of enrolled patients, 58% died during the study (n=161); mean age was 62.3 years (95% CI, 58.9-65.6 years); 55% were women (n=88). These patients were cared for by 76 of the 91 enrolled clinicians (37 intervention, 39 control); years in practice, 11.5 (95% CI, 9.2-13.8); 57% female (n=43). Medical record review after patients' death demonstrated that a significantly higher proportion of intervention patients had a documented discussion compared with controls (96% vs 79%, P = .005) and intervention conversations occurred a median of 2.4 months earlier (median, 143 days vs 71 days, P < .001). Conversation documentation for intervention patients was significantly more comprehensive and patient centered, with a greater focus on values or goals (89% vs 44%, P < .001), prognosis or illness understanding (91% vs 48%, P < .001), and life-sustaining treatment preferences (63% vs 32%, P = .004). Documentation about end-of-life care planning did not differ between arms (80% intervention vs 68% control, P = .08). Significantly more intervention patients had documentation that was accessible in the EMR (61% vs 11%, P < .001). CONCLUSIONS AND RELEVANCE: This communication quality-improvement intervention resulted in more, earlier, better, and more accessible serious illness conversations documented in the EMR. To our knowledge, this is the first such study to demonstrate improvement in all 4 of these outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01786811.

A Systematic Intervention To Improve Serious Illness Communication In Primary Care.

Improving communication about goals and values for patients with advancing serious illness nearing the end of life is a key opportunity to improve the value of care. The Serious Illness Care Program, implemented at primary care clinics affiliated with Brigham and Women's Hospital in Boston, Massachusetts, is a multicomponent intervention designed to support best practices in communication by clinicians to increase conversations with patients with serious illness about their goals and values. We conducted a study of the program in fourteen primary care clinics participating in a high-risk care management program based in an accountable care organization. Patients in the clinics with the program implemented were more likely than those in comparison clinics to have serious illness conversations-including discussion of values and goals-documented in patients' medical records. Clinicians who participated also reported high satisfaction with training they received as part of the program, which they regarded as effective. This work suggests that the Serious Illness Care Program promotes more and better conversations among selected primary care patients, and it highlights the need for further research.

Crisis checklists for the operating room: development and pilot testing.

BACKGROUND: Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures during operating room crises. STUDY DESIGN: We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios. RESULTS: Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04-0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent. CONCLUSIONS: Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.

Bar-coding surgical sponges to improve safety: a randomized controlled trial.

OBJECTIVE: A randomized, controlled trial was performed to evaluate a computer-assisted method for counting sponges using a bar-code system. BACKGROUND: Retained sponges are a rare and preventable problem but persist in surgery despite standardized protocols for counting. Technology that improves detection of counting errors could reduce risk to surgical patients. METHODS: We performed a randomized controlled trial comparing a bar-coded sponge system with a traditional counting protocol in 300 general surgery operations. Observers monitored sponge and instrument counts and recorded all incidents of miscounted or misplaced sponges. Surgeons and operating room staff completed postoperative and end-of-study surveys evaluating the bar-code system. RESULTS: The bar-code system detected significantly more counting discrepancies than the traditional protocol (32 vs.13 discrepancies, P = 0.007). These discrepancies involved both misplaced sponges (21 vs. 12 sponges, P = 0.17) and miscounted sponges (11 vs. 1 sponge, P = 0.007). The system introduced new technical difficulties (2.04 per 1000 sponges) and increased the time spent counting sponges (5.3 vs. 2.4 minutes, P < 0.0001). In postoperative surveys, there was no difference in surgical teams' confidence that all sponges were accounted for, but they rated the counting process and team performance lower in operations randomized to the bar-code arm. By the end of the study, however, most providers found the system easy to use, felt confident in its ability to track sponges, and reported a positive effect on the counting process. CONCLUSIONS: Use of automated counting using bar-coded surgical sponges improved detection of miscounted and misplaced sponges and was well tolerated by surgical staff members.