Understanding WHO surgical checklist implementation: tricks and pitfalls. An observational study.

BACKGROUND: The purpose of the present study was to assess the reliability of implementation data regarding the surgical safety checklist (SSC) and to identify which factors influence actual implementation. METHODS: The study was a retrospective record-based evaluation in a regional network of nine Spanish hospitals, combined with a complementary direct-observation study that included a survey of the surgical teams' attitudes. SSC compliance and associated factors were assessed and compared in a retrospective sample of 280 operations and a concurrent sample of another 85 surgical interventions. RESULTS: In the retrospective evaluation the SSC was present in 83.1 % of cases, fully completed in 28.4 %, with 69.3 % of all possible items checked. The concurrent direct-observation study showed that recorded compliance was unreliable (κ < 0.13 for all items) and significantly higher (p < 0.001) than actual compliance. Over-registration occurred across hospitals and surgical specialties. Factors associated with recorded compliance included hospital size, surgical specialty, and the use of an electronic format. In actual (direct-observation) compliance, a positive attitude on the part of the surgeon is an overriding significant factor (OR 12.8), along with using the electronic format, which is consistently and positively associated with recorded compliance but negatively related to actual compliance. CONCLUSIONS: Recorded SSC compliance may be widely unreliable and higher than actual compliance, particularly when recording is facilitated by using an electronic format. A positive attitude on the part of the surgical team, particularly surgeons, is associated with actual compliance. Effective use of the SSC is a far more complex adaptive process than the usual mandatory strategy.

[Difficulties in implementing a surgical check list in operating theatres]. / Dificultades en la implantación del check list en los quirófanos de cirugía.

OBJECTIVE: To assess the level of implementation and the factors associated with the compliance to the surgical check list (SCL) proposed by the WHO, in surgery departments in public hospitals in the Murcia Region of Spain. METHODOLOGY: A retrospective cross-sectional study was conducted using a random, non-proportional, and stratified sample in each hospital. The sample size was established as 10 cases per centre, with a total of 90 surgical operations. The data analysis included the percentage of compliance of the variables of interest (presence of an SCL and the compliance to it, complete, by sections and by items) at regional level, according to hospital, hospital groups, depending on the size; the type of anaesthesia (local, regional or general); the work shift (morning or afternoon); as well as the age and sex of the surgery patients. RESULTS: The check list was found in the medical records in 75 cases (83.33%; confidence interval [CI]: 78.7% - 87.5%), and complied with in full in 25 cases (27.8%; 95% CI: 18.5% - 37.0%). The percentage of items complied with was 70.1% (95% CI: 67.9%-72.2%). The percentage compliance varied by hospital, from 35.8% to 98.9%. The logistic regression analysis showed significance in the variables such as, the size of the hospital (the list was more likely to be complied with in small and medium hospitals) and operations with local anaesthetic as a negative predictive factor of compliance. CONCLUSIONS: The SCL is used, but is not always complied with, and not homogeneously in all its sections. There is also significant variation between the public hospitals in the Murcia Region of Spain.

Prevention of venous thromboembolism and safe use of heparin in Spanish hospitals.

OBJECTIVE: To assess compliance with basic and actionable indicators in relation to prevention of venous thromboembolism (VTE) and safe use of heparin. DESIGN: We built, pilot tested and measured a set of evidence-based structure (existence of guidelines) and process (risk assessment for VTE, and dose adjustment to patient weight and renal function when prescribing heparin) indicators in a nation-wide random sample of 22 hospitals. Compliance with process indicators is estimated at national level and by groups of hospitals (stratified by size). At hospital level, compliance is assessed with Lot Quality Acceptance Sampling, for 85% compliance standard (α ≤ 0.05), 55% threshold (ß ≤ 0.10). Contents of existing guidelines are analyzed, and their influence on performance is assessed using logistic regression. SETTING: Acute care hospitals in Spain. INTERVENTIONS: None MAIN OUTCOME MEASURES: Problem identification through indicators assessment. RESULTS: Less than half of hospitals have guidelines and their contents are very variable and incomplete. No hospital complies with the standard for VTE prevention and only one for heparin dose adjustment. Nationally, VTE risk assessment is performed in 5.8% of patients (95% CI: 5.6-6.0), and heparin dose is explicitly adjusted in 17.5% (95% CI: 16.8-18.2). Performance is relatively higher in large hospitals and it is associated with the existence of guidelines for VTE prevention (OR: 8.3; 95% CI: 2.1-32.1). CONCLUSIONS: We have identified some actionable contributing factors to safety problems using evidence-based structure and process indicators. Explicit process design and key clinical interventions (risk assessment for VTE and heparin dose adjustment) should be addressed to improve the current situation.

[Analysis of the patient safety culture in hospitals of the Spanish National Health System]. / Análisis de la cultura sobre seguridad del paciente en los hospitales del Sistema Nacional de Salud español.

BACKGROUND AND OBJECTIVES: A safety culture is essential to minimize errors and adverse events. Its measurement is needed to design activities in order to improve it. This paper describes the methods and main results of a study on safety climate in a nation-wide representative sample of public hospitals of the Spanish NHS. MATERIAL AND METHOD: The Hospital Survey on Patient Safety Culture questionnaire was distributed to a random sample of health professionals in a representative sample of 24 hospitals, proportionally stratified by hospital size. Results are analyzed to provide a description of safety climate, its strengths and weaknesses. Differences by hospital size, type of health professional and service are analyzed using ANOVA. RESULTS: A total of 2503 responses are analyzed (response rate: 40%, (93% from professionals with direct patient contact). A total of 50% gave patient safety a score from 6 to 8 (on a 10-point scale); 95% reported < 2 events last year. Dimensions "Teamwork within hospital units" (71.8 [1.8]) and "Supervisor/Manager expectations and actions promoting safety" (61.8 [1.7]) have the highest percentage of positive answers. "Staffing", "Teamwork across hospital units", "Overall perceptions of safety" and "Hospital management support for patient safety" could be identified as weaknesses. Significant differences by hospital size, type of professional and service suggest a generally more positive attitude in small hospitals and Pharmacy services, and a more negative one in physicians. CONCLUSIONS: Strengths and weaknesses of the safety climate in the hospitals of the Spanish NHS have been identified and they are used to design appropriate strategies for improvement.

Ensuring evidence-based practices for falls prevention in a nursing home setting.

OBJECTIVE: To evaluate the effectiveness of an ad hoc multifaceted program to improve structure, professional behavior, and outcomes related to falls prevention. DESIGN: Internal quality improvement cycle. SETTING: Nursing home in Spain. PARTICIPANTS: An institution with 130 residents. INTERVENTION: Local building of quality criteria, audit and feedback, and a specific intervention to improve based on educational and sensitization activities and changes in the process and recording systems. MEASUREMENT: Quality of falls prevention was assessed using reliable evidence-based criteria (4 of structure and 9 of process), at baseline and 6 months after a specific intervention to improve. Number of falls was recorded in a random sample (n = 60) of residents (≥ 65 years) during a 1-year follow-up and summarized fortnightly as an indicator analyzed using a statistical control chart. RESULTS: Baseline structure and fall prevention practices were poor. After the intervention, all structure criteria were present and 8 of 9 process criteria improved significantly. Thirty-two falls occurred 6 months before and 21 after the intervention started, showing a significant decrease in the fortnightly incidence (P < .01). CONCLUSIONS: Adherence to evidence-based recommendations was poor in our setting, but the internal quality improvement cycle was useful in ensuring safe practices and in achieving better outcomes.

[Strategies for patient participation in continuing improvement of clinical safety]. / Estrategias para la participación del paciente en la mejora continua de la seguridad clínica.

Strategies for patient participation in quality improvement, as an active part of processes or providing relevant information when asked, have progressed to a great extent for the last few years, influenced by the emphasis on patient-focused care as a key dimension for quality and, lately, by the emphasis on patient safety -a dimension for which the patient contribution can not be ignored. However, these strategies have not been fully implemented and used in most quality management systems. This article aims to make it easier to select the appropriate strategies for a given context, by describing them, grouped in three main themes (mobilising patients for patient safety; promoting active participation of patients in the prevention of safety incidents; requesting and using the relevant information for quality improvement that patients can provide), illustrating them with examples, and pointing out some of the obstacles for implementing them.

Why hypertensive patients do not comply with the treatment: results from a qualitative study.

BACKGROUND: Medical non-compliance has been identified as a major public health problem in the treatment of hypertension. There is a large research record focusing on the understanding of this phenomenon. However, to date, the majority of studies in this field have been focused from the medical care perspective, but few studies have focused on the patients' point of view. OBJECTIVE: Our aim was to identify factors related to non-compliance with the treatment of patients with hypertension. METHODS: We use a qualitative study in which data were gathered from seven focus group discussions conducted in March-May 2001. Patients were identified as non-compliant, using the Morisky-Green test, at two primary health care centres of the Spanish National Health Service. RESULTS: A complex web of factors was identified that influenced non-compliance. Patients had fears and negative images of antihypertensive drugs. The data also revealed a lack of basic background knowledge about hypertension. The clinical encounter was viewed as unsatisfactory because of its length, few explanations given by the physician and low physician-patient interaction. CONCLUSIONS: Most of the factors related to poor compliance have implications for patient management. Knowing patients' priorities regarding the most important aspects of care that have high potential for low compliance may be helpful in improvement of the quality of hypertensive patient care.

Validity and reliability of guidelines for neck pain treatment in primary health care. A nationwide empirical analysis in Spain.

OBJECTIVES: To assess the reliability and validity of existing clinical guidelines on neck-pain physiotherapy treatment and follow-up in Spain. DESIGN: We identified existing guidelines through a nationwide census and listed their recommendations, grouped according to the main steps of the process flow-chart. To assess reliability we analysed the variability of statements. To analyse validity we assessed the type of scientific evidence supporting the recommendations, and we compared them with a list of evidence-based recommendations that was elaborated for this study. SETTING AND PARTICIPANTS: Primary health care centres (n = 24) with guidelines for neck-pain treatment and follow-up. MAIN OUTCOME MEASURES: We quantified the number of recommendations, the proportion of valid statements, the frequencies of non-evidence-based recommendations, and the absence of the evidence-based recommendations we had identified. RESULTS: The 34 identified guidelines contained 325 recommendations, with great variation between guidelines with respect to the number, type (for up to 26 different clinical decisions), and content of the recommendations they provided. Direct assessment of the scientific evidence was not possible because no specific reference was given to support any recommendation. When compared with our list, only 20.9% of the recommendations could be considered evidence-based. No guideline contained all the eight evidence-based recommendations we identified. CONCLUSIONS: The results question the guidelines' reliability and validity, and their usefulness in ensuring quality. We conclude that guidelines should be reviewed and re-designed with greater scientific rigour.

Dificultades en la implantación del check list en los quirófanos de cirugía / Difficulties in implementing a surgical check list in operating theatres

Introducción La hemorragia venosa presacra durante la movilización del recto es baja, pero a menudo masiva e incluso letal. Nuestro objetivo conocer in vitro el resultado de la electrocoagulación aplicada a un fragmento de músculo sobre la superficie del hueso sacro y comunicar nuestros resultados en el control del sangrado venoso presacro durante la resección rectal por neoplasia maligna de recto. Material y Método In vitro se aplicó coagulación monopolar con selector al máximo de potencia sobre un fragmento muscular de 2×2cm aplicado a la cara anterior de la IV vértebra sacra hasta conseguir el punto de ebullición. Este método fue usado en 6 pacientes con hemorragia del plexo venoso presacro. Resultados En el estudio in vitro se alcanzó el punto de ebullición a los 90s. de la aplicación de corriente monopolar sobre el fragmento muscular. En 6 pacientes con hemorragia venosa presacra se aplicó electrocoagulación a un fragmento de músculo recto abdominal de 2×2cm presionado sobre la superficie del hueso sacro, logrando el cese del sangrado en todos los casos. Conclusiones El uso de electrocoagulación indirecta sobre un fragmento de músculo recto abdominal es una técnica sencilla y altamente efectiva en el control de la hemorragia venosa presacra (AU)

Introduction Presacral venous haemorrhage during rectal movement is low, but is often massive, and even fatal. Our objective is the "in vitro" determination of the results of electrocoagulation applied to a fragment of muscle on the sacral bone surface during rectal resection due to a malignant neoplasm of the rectum. Material and method Single-pole coagulation was applied "in vitro" with the selector at maximum power on a 2×2cms muscle fragment, applied to the anterior side of the IV sacral vertebra until reaching boiling point. The method was used on 6 patients with bleeding of the presacral venous plexus. Results In the "in vitro" study, boiling point was reached in 90seconds from applying the single-pole current on the muscle fragment. Electrocoagulation was applied to a 2×2cm rectal muscle fragment in 6 patients with presacral venous haemorrhage, using pressure on the surface of the presacral bone, with the stopping of the bleeding being achieved in all cases. Conclusions The use of indirect electrocoagulation on a fragment of the rectus abdominis muscle is a straightforward and highly effective technique for controlling presacral venous haemorrhag (AU)

Estrategias para la participación del paciente en la mejora continua de la seguridad clínica / Strategies for patient participation in continuing improvement of clinical safety

Las estrategias enfocadas a la participación del paciente en la mejora de la calidad, sea de forma activa o a instancias del sistema, han experimentado un gran desarrollo en los últimos años, de la mano del enfoque en el usuario como una de las dimensiones clave de la calidad y, últimamente, por el énfasis en la seguridad, para la cual el papel del paciente no puede ser ignorado. Sin embargo, su incorporación plena a los sistemas de gestión de la calidad sigue siendo, en gran medida, una tarea pendiente. El objetivo de este artículo es contribuir a esta incorporación, facilitando la selección de las estrategias y acciones más adecuadas para cada entorno. Con este fi n se describen las tres estrategias principales existentes en la actualidad (la movilización de los pacientes para su seguridad; promover la participación activa del paciente en la prevención de incidentes de seguridad; solicitar y utilizar la información relevante que pueden aportar los pacientes), se señalan ejemplos y, en su caso, barreras para su implementación (AU))

Strategies for patient participation in quality improvement, as an active part of processes or providing relevant information when asked, have progressed to a great extent for the last few years, influenced by the emphasis on patient-focused care as a key dimension forquality and, lately, by the emphasis on patient safety -a dimension for which the patient contribution can not be ignored. However, these strategies have not been fully implemented and used in most quality management systems. This article aims to make it easier to select the appropriate strategies for a given context, by describing them, grouped in three main themes (mobilising patients for patient safety; promoting active participation of patients in the prevention of safety incidents; requesting and using the relevant information for quality improvement that patients can provide), illustrating them with examples, and pointing out some of the obstacles for implementing them (AU)

¿Los protocolos de enfermería siguen los requisitos de calidad estructural? Resultados de una evaluación multicéntrica en atención primaria de salud / Do Nursing Protocols Meet Structural Quality Requirements? Results of a Multicenter Evaluation in Primary Health Care

Objetivo: Determinar la calidad estructural de los protocolos de enfermería en el ámbito de la atención primaria de salud de la región de Murcia y analizar los factores asociados. Diseño: Evaluación retrospectiva. Emplazamiento: Centros de salud de la región de Murcia. Pacientes u otros participantes: Conjunto de protocolos accesibles de enfermería elaborados entre 1985 y 1993 (147 en total).Mediciones y resultados principales: se evalúa el grado de cumplimiento de 9 criterios de calidad estructural que han sido definidos a partir del esquema propuesto por el Institute of Medicine. Aproximadamente la mitad de los documentos evaluados no se ajusta al concepto de protocolo y ninguno reúne de forma simultánea todos los requisitos evaluados. De hecho, solamente 2 criterios se cumplen en más del 60 por ciento de los protocolos. Además, la observancia es inferior al 25 por ciento en 4 criterios (C3: "existencia de un mecanismo de evaluación"; C4: "incluye algún algoritmo"; C7: "incluye un índice paginado", y C9: "adjunta las referencias bibliográficas"). Por otra parte, la calidad es ligeramente superior en los protocolos de actividades preventivas y en los que se refieren a la mujer. Sin embargo, los que forman parte de un programa de salud o los que están acreditados presentan más defectos de calidad. Conclusiones: Existe un amplio margen de mejora en la calidad estructural de los protocolos de enfermería. La elaboración de estas herramientas requiere del seguimiento y aplicación de esquemas de referencia o de "protocolos de diseño de los protocolos clínicos" para prevenir los numerosos defectos estructurales que se pueden producir (AU)