Adapting the World Health Organization's Surgical Safety Checklist to High-Income Settings: A Hybrid Effectiveness-Implementation Trial Protocol.

Objectives: The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background: The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods: A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis: Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting: The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact: We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.

Informed consent for medical student involvement in patient care: an updated consensus statement.

Enabling patients to consent to or decline involvement of medical students in their care is an essential aspect of ethically sound, patient-centred, mana-enhancing healthcare. It is required by Aotearoa New Zealand law and Te Kaunihera Rata o Aotearoa Medical Council of New Zealand policy. This requirement was affirmed and explored in a 2015 Consensus Statement jointly authored by the Auckland and Otago Medical Schools. Student reporting through published studies, reflective assignments and anecdotal experiences of students and teachers indicate procedures for obtaining patient consent to student involvement in care remain substandard at times. Between 2020 and 2023 senior leaders of Aotearoa New Zealand's two medical schools, and faculty involved with teaching ethics and professionalism, met to discuss these challenges and reflect on ways they could be addressed. Key stakeholders were engaged to inform proposed responses. This updated consensus statement is the result. It does not establish new standards but outlines Aotearoa New Zealand's existing cultural, ethical, legal and regulatory requirements, and considers how these may be reasonably and feasibly met using some examples.

Using Days Alive and Out of Hospital to measure inequities and possible pathways for them after cardiovascular surgery in Aotearoa New Zealand: study protocol for a secondary data analysis.

INTRODUCTION: In Aotearoa New Zealand (NZ), socioeconomic status and being of Maori ethnicity are often associated with poorer health outcomes, including after surgery. Inequities can be partially explained by differences in health status and health system biases are hypothesised as important factors for remaining inequities. Previous work identified inequities between Maori and non-Maori following cardiovascular surgery, some of which have been identified in studies between 1990 and 2012. Days Alive and Out of Hospital (DAOH) is an emerging surgical outcome metric. DAOH is a composite measure of outcomes, which may reflect patient experience and longer periods of DAOH may also reflect extended interactions with the health system. Recently, a 1.1-day difference in DAOH was observed between Maori and non-Maori at a hospital in NZ across a range of operations. METHODS AND ANALYSIS: We will conduct a secondary data analysis using data from the National Minimum Data Set, maintained by the Ministry of Health. We will report unadjusted and risk-adjusted DAOH values between Maori and non-Maori using direct risk standardisation. We will risk adjust first for age and sex, then for each of deprivation (NZDep18), levels of morbidity (M3 score) and rurality. We will report DAOH values across three time periods, 30, 90 and 365 days and across nine deciles of the DAOH distribution (0.1-0.9 inclusive). We will interpret all results from a Kaupapa Maori research positioning, acknowledging that Maori health outcomes are directly tied to the unequal distribution of the social determinants of health. ETHICS AND DISSEMINATION: Ethics approval for this study was given by the Auckland Health Research Ethics Committee. Outputs from this study are likely to interest a range of audiences. We plan to disseminate our findings through academic channels, presentations to interested groups including Maori-specific hui (meetings), social media and lay press.

Using days alive and out of hospital to measure surgical outcomes in New Zealand: a cross-sectional study.

OBJECTIVES: To measure differences at various deciles in days alive and out of hospital to 90 days (DAOH90) and explore its utility for identifying outliers of performance among district health boards (DHBs). METHODS: Days in hospital and mortality within 90 days of surgery were extracted by linking data from the New Zealand National Minimum Data Set and the births and deaths registry between 1 January 2011 and 31 December 2021 for all adults in New Zealand undergoing acute laparotomy (AL-a relatively high-risk group), elective total hip replacement (THR-a medium risk group) or lower segment caesarean section (LSCS-a low-risk group). DAOH90 was calculated without censoring to zero in cases of mortality. For each DHB, direct risk standardisation was used to adjust for potential confounders and presented in deciles according to baseline patient risk. The Mann-Whitney U test assessed overall DAOH90 differences between DHBs, and comparisons are presented between selected deciles of DAOH90 for each operation. RESULTS: We obtained national data for 35 175, 52 032 and 117 695 patients undergoing AL, THR and LSCS procedures, respectively. We have demonstrated that calculating DAOH without censoring zero allows for differences between procedures and DHBs to be identified. Risk-adjusted national mean DAOH90 Scores were 64.0 days, 79.0 days and 82.0 days at the 0.1 decile and 75.0 days, 82.0 days and 84.0 days at the 0.2 decile for AL, THR and LSCS, respectively, matching to their expected risk profiles. Differences between procedures and DHBs were most marked at lower deciles of the DAOH90 distribution, and outlier DHBs were detectable. Corresponding 90-day mortality rates were 5.45%, 0.78% and 0.01%. CONCLUSION: In New Zealand after direct risk adjustment, differences in DAOH90 between three types of surgical procedure reflected their respective risk levels and associated mortality rates. Outlier DHBs were identified for each procedure. Thus, our approach to analysing DAOH90 appears to have considerable face validity and potential utility for contributing to the measurement of perioperative outcomes in an audit or quality improvement setting.

Emotions and team communication in the operating room: a scoping review.

Training in healthcare team communication has largely focused on strategies to improve information transfer with less focus on interpersonal dynamics and emotional aspects of communication. The Operating Room (OR) may be one of the most emotionally charged hospital environments, and is one requiring excellent team communications. We aimed to identify literature reporting on the emotional aspects of OR team communication. Our research questions were: what are the triggers in the environment that provoke an emotional response affecting communication, and what are the emotional responses to communication between OR team members; and how do these emotional aspects of communication affect the function of the OR team? We undertook a Scoping Review of literature across relevant databases following published guidelines, and narrative synthesis of the identified studies. From the 10 included studies we identified three themes: (1) Emotional experiences in the OR and their contributors; (2) Effects of emotional experiences on team communication; and (3) Solutions to manage the emotional experiences in the OR. Theme 1 sub-themes were: (1) Range of emotions experienced in the OR; (2) Hierarchical culture and (3) Leadership expectations as contributors to negative emotions. The OR is an emotionally charged environment. The hierarchical culture can inhibit staff from speaking up, and failure of leaders to meet team expectations, e.g., through appropriate and timely communication, may cause frustration and stress. The consequences of emotions include poor team dynamics, ineffective communication and potential negative impact on patient care. Few studies described strategies to manage emotions in the OR. The studies reviewed describe an environment where emotions can run high, affecting interpersonal communications, team function and patient care. The few identified studies relevant to our research questions demonstrate a need to better understand the emotional aspects of OR team communication and the effectiveness of interventions to improve these.

Perioperative oxygen administration in patients undergoing major non-cardiac surgery under general anaesthesia in Australia and New Zealand.

The practice of anaesthetists relating to the administration of intraoperative oxygen has not been previously quantified in Australia and New Zealand. The optimal regimen of intraoperative oxygen administration to patients undergoing surgery under general anaesthesia is not known, and international recommendations for oxygen therapy are contradictory; the World Health Organization (WHO) recommend administering an intraoperative fraction of inspired oxygen of at least 0.8, while the World Federation of Societies of Anaesthesiologists, British Thoracic Society, and Thoracic Society of Australia and New Zealand recommend a more restrictive approach. We conducted a prospective observational study to describe the pattern of intraoperative oxygen administration among anaesthetists in Australia and New Zealand and, second, to determine the proportion of anaesthetists who administer intraoperative inspired oxygen in accordance with the WHO recommendations. We identified 150 anaesthetists from ten metropolitan hospitals in Australia and New Zealand and observed the patterns of intraoperative oxygen administration to American Society of Anesthesiologists physical status classification (ASA) 3 or 4 patients undergoing prolonged surgery under general anaesthesia. The median (interquartile range) intraoperative time-weighted mean fraction of inspired oxygen (FiO2) for all participants in the study was 0.47 (0.40-0.55). Three out of 150 anaesthetists (2%, 95% confidence interval 0.4 to 5.7) administered an average intraoperative FiO2 of at least 0.8. These findings indicate that most anaesthetists routinely administer an intermediate level of oxygen for ASA 3 or 4 adult patients undergoing prolonged surgery in Australia and New Zealand, rather than down-titrating inspired oxygen to a target pulse oximetry reading (SpO2) or administering liberal perioperative oxygen therapy in line with the current WHO recommendation.

A prospective observational study on the effect of emboli exposure on cerebral autoregulation in cardiac surgery requiring cardiopulmonary bypass.

OBJECTIVE: Cerebrovascular autoregulation impairment has been associated with stroke risk in cardiac surgery. We hypothesized that greater arterial emboli exposure in open-chamber surgery might promote dysautoreguation. METHODS: Forty patients underwent closed or open-chamber surgery. Transcranial Doppler detected emboli and measured bilateral middle cerebral artery flow velocities. Cerebral autoregulation was assessed by averaging the mean velocity index ("Mx," a continuous moving correlation between cerebral blood flow velocity and mean arterial pressure) over 30 min before and after aortic cross-clamp removal. RESULTS: Median (interquartile range) emboli counts were 775 (415, 1211) and 2664 (793, 3734) in the closed-chamber and open-chamber groups. Most appeared after the removal of the aortic cross-clamp (open-chamber 1631 (606, 2296)), (closed-chamber 229 (142, 384)), with emphasis on the right hemisphere (open-chamber: 826 (371, 1622)), (closed-chamber 181 (66, 276)). Linear mixed model analyses of mean velocity index change showed no significant overall effect of group (0.08, 95% CI: -0.04, 0.21; p = 0.19) or side (0.01, 95% CI: -0.03, 0.05; p = 0.74). There was an interaction between group and side (p = 0.001), manifesting as a greater increase in mean velocity index in the right hemisphere in the open than the closed group (mean difference: 0.15, 95% CI: 0.02, 0.27; p = 0.03). CONCLUSIONS: Overall, change in mean velocity index before and after cross-clamp removal did not differ between groups. However, most emboli entered the right cerebral hemisphere where this change was significantly greater in the open-chamber group, suggesting a possible association between embolic exposure and dysautoregulation.

Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet.

An error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.

Medical students and informed consent-response to "Consent for Teaching".

Nil.

Days alive and out of hospital after laparoscopic cholecystectomy.

BACKGROUND: Days alive and out of hospital (DAOH) is a metric that incorporates several outcomes into a single, standardized measure. This study aimed to explore the utility of DAOH in assessing the outcomes of a retrospective cohort of patients undergoing laparoscopic cholecystectomy (LC). METHODS: Patients undergoing LC at Auckland City Hospital between 1 January 2010 and 31 August 2015 were included. DAOH values were calculated for the 90 days from the date of surgery (DAOH90 ) and described using median and interquartile ranges (IQR). DAOH90 distributions were compared using a two-tailed (non-parametric) Wilcoxon-Mann-Whitney test. RESULTS: 1652 patients undergoing LC were studied. Patients experiencing complications (n = 70, 4.2%) had fewer DAOH90 (median 83, IQR 79, 86) than patients who underwent uncomplicated LC (median 88, IQR 86, 88), P < 0.001. Patients who were converted to open cholecystectomy (n = 70, 4.2%) also had fewer DAOH90 (median 82.5, IQR 79, 84) than patients who underwent uncomplicated LC, P < 0.001. Post-operative complications and conversion had a statistically significant effect on DAOH90 at each of the tested quantiles, except for conversion at the 0.1 quantile. CONCLUSION: DAOH90 is readily calculable from existing New Zealand administrative data sources and is sensitive to the occurrence of complications after LC.

A rose by any other name would smell as sweet: defining patient safety-related terminology.

The definitions of terms related to iatrogenic harm and the potential for iatrogenic harm (e.g. error, medication error, near miss) in the anaesthesia literature are imprecise and variable, resulting in wide discrepancy in conclusions about their rates and potential solutions. Clarification of these terms is both critical and difficult: a concerted effort to achieve expert consensus is warranted.

Hospital accreditation processes in Saudi Arabia: a thematic analysis of hospital staff experiences.

BACKGROUND: Hospital accreditation by an international organisation can play an important role in health quality and safety. However, little is known about how managers and front-line employees experience and perceive the effects of accreditation. Their views could inform quality improvement processes and procedures. OBJECTIVE: To explore perceptions of employees at the managerial level on the Joint Commission International (JCI) accreditation process and its impact on quality of patient care in Saudi Arabian JCI-accredited hospitals. METHODS: We undertook a qualitative study using semi-structured interviews to explore the perspectives of senior staff from three accredited public hospitals in Saudi Arabia. Interviews were transcribed prior to thematic analysis. RESULTS: Twenty managers participated in the interviews. The following inter-related themes emerged concerning the JCI accreditation process and its impact on quality of patient care: drivers for the change; the plan for the change; the process of the change; maintaining changes post-accreditation and patients' issues. Participants were positive in their accounts of: drivers for the change; planning for the change needed to achieve accreditation and managing patients' issues. However, participants reported less favourably on: the process of the change; and maintaining changes post-accreditation. CONCLUSION: The planning stage was perceived as the easiest component of JCI accreditation. Implementing and maintaining changes post-accreditation that demonstrably promote patient safety and quality of care was perceived as more difficult. When planning for accreditation, institutions need to incorporate strategies to ensure that improvements to care continue beyond the accreditation period.

Clinicians' experiences of inquiries following mental health related homicide: a qualitative study.

OBJECTIVES: This aim of this qualitative study was to explore the experiences of clinicians involved with inquiries into the mental health care of patients who were perpetrators of homicide in New Zealand. METHODS: Our purposive sample comprised ten clinicians working in New Zealand district health board mental health services. These clinicians were individually interviewed. Interviews were audio-recorded, transcribed and thematically analysed. The coding framework was checked and peer reviewed by an independent researcher. RESULTS: Five themes were identified: the inquiry process; emotional burden; impact on team dynamics; changes to individual clinical practice; and perceptions of inquiries being influenced by organisational culture. Clinicians involved with inquiries reported significant anxiety and disrupted multidisciplinary team dynamics. Some participants found inquiries led to changes to their clinical practice and perceived that a punitive organisational culture limited learning. CONCLUSIONS: Clinicians perceived inquiries as threatening, anxiety provoking and primarily concerned with protecting organisational interests. Communication of the inquiry process and ensuring inquiry findings are disseminated may enhance clinicians' experiences of inquiries and facilitate their participation and their reflection on changes to clinical practice that could contribute to improving services. Support for clinicians and multidisciplinary teams should be emphasised by the commissioning agency.

A prospective observational study of emboli exposure in open versus closed chamber cardiac surgery.

OBJECTIVE: Exposure to cerebral emboli is ubiquitous and may be harmful in cardiac surgery utilizing cardiopulmonary bypass. This was a prospective observational study aiming to compare emboli exposure in closed-chamber with open-chamber cardiac surgery, distinguish particulate from gaseous emboli and examine cerebral laterality in distribution. METHODS: Forty patients underwent either closed-chamber procedures (n = 20) or open-chamber procedures (n = 20). Emboli (gaseous and solid) were detected using transcranial Doppler in both middle cerebral arteries in two monitoring phases: 1, initiation of bypass to the removal of the aortic cross-clamp; and 2, removal of aortic cross-clamp to 20 minutes after venous decannulation. RESULTS: Total (median (interquartile range)) emboli counts (both phases) were 898 (499-1366) and 2617 (1007-5847) in closed-chamber and open-chamber surgeries, respectively. The vast majority were gaseous; median 794 (closed-chamber surgery) and 2240 (open-chamber surgery). When normalized for duration, there was no difference between emboli exposures in closed-chamber and open-chamber surgery in phase 1: 6.8 (3.6-15.2) versus 6.4 (2.0-18.1) emboli per minute, respectively. In phase 2, closed-chamber surgery cases were exposed to markedly fewer emboli than open-chamber surgery cases: 9.6 (5.1-14.9) versus 43.3 (19.7-60.3) emboli per minute, respectively. More emboli (total) passed into the right cerebral circulation: 985 (397-2422) right versus 376 (198-769) left. CONCLUSIONS: Patients undergoing open-chamber surgery are exposed to considerably higher numbers of cerebral arterial emboli after removal of the aortic cross-clamp than those undergoing closed-chamber surgery, and more emboli enter the right middle cerebral artery than the left. These results may help inform the evaluation of the pathophysiological impact of emboli exposure.

Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS.

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.

A cross-sectional overview of the second 4000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand.

This cross-sectional overview of the second 4000 incidents reported to webAIRS has findings that are very similar to the previous overview of the first 4000 incidents. The distribution of patient age, body mass index and American Society of Anesthesiologists physical status was similar, as was anaesthetist gender, grade, location and time of day of incidents. About 35% of incidents occurred during non-elective procedures (vs. 33% in the first 4000 incidents). The proportion of incidents in the various main categories was also similar, with respiratory/airway being most common, followed by cardiovascular, medication-related and medical device or equipment-related incidents. Together these categories made up about 78% of all incidents in both overviews. The immediate outcome was comparable with reports of harm in about a quarter of incidents and a similar rate of deaths (4.7% vs. 4.2%). However, the proportion of patients who had received total intravenous anaesthesia was higher (17.6% vs. 7.7%) and the proportion of patients who received combined intravenous and inhalational anaesthesia was lower (52.3% vs. 58.4%), as was the proportion receiving local anaesthesia alone (1.6% vs. 6.7%). There was a small increase in the number of incidents resulting in unplanned admission to a high dependency or intensive care unit (18.1% vs. 13.5%). It is not clear whether these differences represent trends or random observations. About 48% of incidents were considered preventable by the reporters (vs. 52% in the first 4000). These findings support continued emphasis on human and system factors to promote and improve patient safety in anaesthesia care.

Reporting of Clinical Outcomes After Endovascular Aortic Aneurysm Repair: A Systematic Review.

BACKGROUND: Endovascular aneurysm repair (EVAR) is an established treatment for many patients with infra-renal abdominal aortic aneurysm (AAA). Reporting standards were published in 2002 to ensure consistent measurement and reporting of outcomes following EVAR. We aimed to assess the range of clinical outcomes reported after EVAR and whether recent studies adhere to established reporting standards. METHODS: We searched MEDLINE and Embase from January 2014 until December 2018, using terms for 'EVAR' and 'AAA'. We included prospective studies and randomised controlled trials which reported clinical outcomes of elective infra-renal AAA repair. Data on clinical outcome reporting were extracted and compared with established reporting standards. RESULTS: 84 studies were included. Technical success was reported in 49 (58.3%) studies, but only defined in 40 (47.6%), with 22 distinct definitions. Clinical success was reported and defined in 19 (22.6%) studies. Aneurysm rupture was reported in 27 (32.1%) studies and death from rupture in 11 (13.1%) studies. All-cause and aneurysm-related mortality were reported in 72 (85.7%) and 52 (61.9%) studies, respectively. Endoleak type I (n = 61, 72.6%) and II (n = 52, 61.9%) were more commonly reported than type III (n = 45, 53.6%) or IV (n = 13, 15.5%). Complications and mortality were reported by a mean of 18 (21.4%) and 42 (50%) studies, respectively. CONCLUSIONS: A wide variety of clinical outcomes were reported following EVAR. Few studies adhered to reporting guidelines. We recommend modification of reporting standards to reflect advances in endovascular technology and creation of a core outcome set for EVAR.

Communication and team function affect patient outcomes in anaesthesia: getting the message across.

A study in this edition of the Journal has added to data showing that failures in communication in the operating room contribute to patient harm. These data support the view that multidisciplinary teamwork and communication training should be part of the continuous professional development of all members of the perioperative team. Achieving change will require efforts to win the hearts and minds of all concerned, but these data also support an expectation that engagement in initiatives and techniques to enhance communication and teamwork should not be optional.