What are we missing? The quality of intraoperative handover before and after introduction of a checklist.

PURPOSE: Intraoperative handovers are common in anesthesia practice and are associated with increased patient morbidity and mortality. Checklists may improve transfer of information during handovers. This before-and-after study sought to examine the effect of a checklist on intraoperative handover. We hypothesized that introducing a handover checklist would improve our primary outcome of completeness of data transfer. METHODS: From February to August 2016, anesthesia providers (residents, fellows, and consultants) at a single tertiary academic center participated in a handover study. Baseline handovers between anesthesia care providers were videotaped, analyzed, and compared with anesthetic records. An intraoperative handover checklist was then introduced, and handovers completed with it were videotaped. The completeness of handovers was compared between the baseline routine and checklist groups. The primary outcome was completeness of information transfer. RESULTS: Sixty-seven anesthesia providers participated in the study. Use of the intraoperative handover checklist improved completeness of handover by 6% (95% confidence interval [CI], 2 to 10; P < 0.01). There was no relationship observed between the provider (consultants/fellows vs resident) of the handovers and the degree of completeness (95% CI, 3 to 8; P = 0.33). Complexity had a significant impact on the handover completeness with low or high complexity cases more completely handed over than those of medium complexity both before and after the intervention-a 6% increase for low complexity (95% CI, 1 to 11; P = 0.02) and a 9% increase for high complexity (95% CI, 3 to 14; P < 0.01). CONCLUSION: Use of a checklist during intraoperative handovers improved completeness of data transfer. Handover checklists should be considered to improve handover completeness.

RéSUMé: OBJECTIF: Les transferts peropératoires sont fréquents dans la pratique de l'anesthésie et sont associés à une augmentation de la morbidité et de la mortalité des patients. Les listes de vérification pourraient améliorer le transfert d'informations pendant les transitions. Cette étude avant-après a cherché à examiner l'effet d'une liste de vérification sur les transferts peropératoires. Nous avons émis l'hypothèse que l'introduction d'une liste de vérification de transfert améliorerait notre critère d'évaluation principal, nommément la complétude du transfert des informations. MéTHODE: De février à août 2016, des prestataires d'anesthésie (résidents, fellows et consultants) d'un seul centre universitaire tertiaire ont participé à une étude sur les transferts. Les transferts de base entre les fournisseurs de soins d'anesthésie ont été filmés, analysés et comparés aux dossiers d'anesthésie. Une liste de contrôle de transfert peropératoire a ensuite été introduite, et les transferts réalisés avec celle-ci ont été filmés. La complétude des transferts a été comparée entre les groupes faisant un transfert normal de base et ceux utilisant la liste de vérification. Le critère d'évaluation principal était la complétude du transfert d'informations. RéSULTATS: Soixante-sept fournisseurs d'anesthésie ont participé à l'étude. L'utilisation de la liste de vérification de transfert peropératoire a amélioré la complétude du transfert de 6 % (intervalle de confiance [IC] à 95 %, 2 à 10; P < 0,01). Aucune relation n'a été observée entre le fournisseur (consultants/fellows) vs résidents) responsable des transferts et le degré de complétude du transfert (IC 95 %, 3 à 8; P = 0,33). La complexité a eu un impact significatif sur la complétude du transfert, les cas de basse ou haute complexité étant transférés de manière plus complète que les cas de complexité moyenne, tant avant qu'après l'intervention ­ avec une augmentation de 6 % pour les cas de faible complexité (IC 95 %, 1 à 11; P = 0,02) et une augmentation de 9 % pour les cas de complexité élevée (IC 95 %, 3 à 14; P < 0,01). CONCLUSION: L'utilisation d'une liste de vérification lors des transferts peropératoires a amélioré la complétude du transfert des informations. Les listes de vérification de transfert devraient être envisagées pour améliorer la complétude des transferts.

Incident Management in Health Care: A Pan-Canadian Perspective.

BACKGROUND: Nearly 10% of patients experience a harmful patient safety incident in the hospital setting. Current evidence focuses on incident reporting, whereas little is known about how incidents are managed within organizations. PURPOSE: The aim of this study was to explore processes, tools, and resources for incident management in Canadian health care organizations. METHODS: Qualitative focus groups were conducted with key stakeholders, representing clinicians, managers, executives, governors, patients, and families (n = 45). RESULTS: Qualitative data were thematically analyzed and presented as 3 themes: (1) variations in incident reporting and management; (2) simplification of the incident management process; and (3) need for leadership to support just culture and redefine harm. CONCLUSION: The study findings support and inform efforts to create a patient safety culture in Canadian and international health care organizations. There is a need to develop a standardized, accessible incident reporting and management system for use across health care sectors to promote continuous learning and improvement about patient safety.

Assessment of the effectiveness of weight-adjusted antibiotic administration, for reduced duration, in surgical prophylaxis of primary hip and knee arthroplasty.

BACKGROUND: Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration. AIM: To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty. METHODS: Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively. RESULTS: A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46]. CONCLUSION: A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.