Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit.
Eur J Cardiothorac Surg
; 41(6): 1326-9, 2012 Jun.
Article
em En
| MEDLINE
| ID: mdl-22219459
ABSTRACT
OBJECTIVES:
There is a significant global burden of preventable morbidity and mortality after surgery caused by avoidable adverse events. Venous thromboembolism (VTE) prophylaxis, despite evidence for its efficacy, is not reliably and consistently prescribed, and is currently a serious concern for patient safety. The aim of this study was to prospectively audit errors captured by an extended surgical time out checklist and relate them to the introduction of a safety culture.METHODS:
The use of an extended surgical time out checklist was prospectively audited, in consecutive patients in one operating theatre over a period of two years. Errors captured were analysed and related to other improvements to safety culture; human factors training, debriefing and regular departmental meetings.RESULTS:
Time out was performed in 959 patients of 990 (96.8%) undergoing thoracic surgery. Performance was consistent over time. Errors were categorized as VTE prophylaxis (n = 53, 6%), blood products (n = 11), clerical (n = 5), imaging (n = 2) and miscellaneous (n = 2). After a lag period of 15 months, during which the team underwent human factors training, introduced debriefing and escalated VTE prophylaxis to regular departmental meetings, VTE prophylaxis errors were substantially reduced. The temporal relationship between error capture and error elimination is explored.CONCLUSIONS:
Use of checklists alongside appropriate human factors training, debriefing and regular multidisciplinary communication can substantially improve VTE prophylaxis in patients undergoing surgery.
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Procedimentos Cirúrgicos Torácicos
/
Tromboembolia Venosa
/
Retroalimentação
/
Lista de Checagem
Tipo de estudo:
Etiology_studies
/
Observational_studies
/
Risk_factors_studies
Limite:
Humans
País/Região como assunto:
Europa
Idioma:
En
Revista:
Eur J Cardiothorac Surg
Assunto da revista:
CARDIOLOGIA
Ano de publicação:
2012
Tipo de documento:
Article
País de afiliação:
Reino Unido