Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

BACKGROUND: Despite being implemented for over a decade, literature describing how the surgical safety checklist (SSC) is completed by operating room (OR) teams and how this relates to its effectiveness is scarce. This systematic review aimed to: (1) quantify how many studies reported SSC completion versus described how the SSC was completed; (2) evaluate the impact of the SSC on provider outcomes (Communication, case Understanding, Safety Culture, CUSC), patient outcomes (complications, mortality rates) and moderators of these relationships. METHODS: A systematic literature search was conducted using Medline, CINAHL, Embase, PsycINFO, PubMed, Scopus and Web of Science on 10 January 2020. We included providers who treat human patients and completed any type of SSC in any OR or simulation centre. Statistical directional findings were extracted for provider and patient outcomes and key factors (eg, attentiveness) were used to determine moderating effects. RESULTS: 300 studies were included in the analysis comprising over 7 302 674 operations and 2 480 748 providers and patients. Thirty-eight per cent of studies provided at least some description of how the SSC was completed. Of the studies that described SSC completion, a clearer positive relationship was observed concerning the SSC's influence on provider outcomes (CUSC) compared with patient outcomes (complications and mortality), as well as related moderators. CONCLUSION: There is a scarcity of research that examines how the SSC is completed and how this influences safety outcomes. Examining how a checklist is completed is critical for understanding why the checklist is successful in some instances and not others.

Getting everyone to the table: exploring everyday and everynight work to consider 'latent social threats' through interprofessional tabletop simulation.

In this methodological intersection article, we describe how we developed a new variation of the established tabletop simulation modality, inspired by institutional ethnography (IE)-informed principles. We aimed to design and conduct pilot implementations of this innovative tabletop simulation modality, which focused uniquely on everyday and everynight work, along with the factors that govern that work. In so doing, we aimed to develop a modality and preliminary findings that researchers and educators can use to simulate healthcare practices across longer episodes of care (i.e., time scales of hours or an entire day) and to detect the 'latent social threats' that can emerge during interprofessional clinical care.An interprofessional team designed tabletop simulation scenarios of interprofessional challenges during transfers of care on a labour and delivery (L&D) unit. Within each scenario, participants provided real-time explanations for their work and associated drivers, both independently and as a team. Thus, we combined 'think-aloud' and simulation principles to design tabletop simulation scenarios to elicit healthcare professionals' descriptions of how they collaborate in their work on the L&D unit. We completed a total of five tabletop simulations with eight participants (obstetricians, N = 2; midwives, N = 2; nurses, N = 5).The conversations stimulated by the tabletop simulation scenarios and debriefs allowed us to generate a preliminary understanding of the texts that govern and organize clinicians' everyday work processes. We generated data about longitudinal, multi-hour work processes in a condensed timeline, with opportunities to pause and probe, and with reduced focus on individual practitioner's competence.We believe our innovative tabletop simulation approach allowed us to examine clinical work in ways no other simulation permits. Participants described how the scenarios opened a productive dialogue between professional groups and suggested this simulation-based approach might contribute to enhanced interprofessional understanding and cultural change. We suggest that others can adapt our low-resource approach to understand clinicians' everyday work and to map how this work is governed by documents, like policies, with the end goal of facilitating system change and managing latent social threats.

"We can't just have a casual conversation": An institutional ethnography-informed study of work in labour and birth.

Labour and delivery units often become contested workplaces with tensions between obstetrics, nursing, and midwifery practices. These tensions can impede communication and raise concerns about provider wellness and patient safety. Remedying such tensions requires inquiry into the drivers of recurrent problems in interprofessional practice. We engaged in change-oriented inquiry informed by institutional ethnography (IE) within an academic hospital in Toronto, Canada (2017-2019). Clinicians identified critical incident analysis reports used to document recurrent issues for transfers of care (TOC) and consultations between professionals. We then mapped the everyday/everynight work of midwives, nurses, and obstetricians by observing (75 h) and interviewing them (n = 15). We also traced work processes to local (forms and hospital policies) and external (national policies and evidence-based guidelines) texts. Our IE-informed analysis made visible the otherwise hidden links between the everyday work of practitioners and its social organization. Three intrapartum work processes involving midwives consulting with obstetricians were identified: induction of labour with TOC back to midwife once labour was "active", consultation without TOC, and TOC for various indications. Three points of disjuncture complicated these processes: (i) a local "3 consult rule", linked to medico-legal governance and remuneration structures; (ii) subjective interpretations of the "4-cm dilation rule", a policy meant to standardize practice; and (iii) regulations delaying the timing of consultations. The Electronic Fetal Monitoring system served as a powerful text, materializing issues of professional scope and autonomy for midwives, and medicolegal accountability for obstetricians. Our study extends extant evidence that medicine-driven governance of midwifery practices can perpetuate interprofessional challenges. While practitioners spoke of the three disjunctures as 'laws', most also viewed them as ostensibly modifiable. Interprofessional tensions may be addressed by considering how social organization, materialized in texts detailing medico-legal liability and remuneration, can constrain possible practices through regulatory protocols, local ruling policies, and cultural expectations (e.g., documentation practices).

Design Thinking-Informed Simulation: An Innovative Framework to Test, Evaluate, and Modify New Clinical Infrastructure.

INTRODUCTION: Designing new healthcare facilities is complex and transitions to new clinical environments carry high risks, as unanticipated problems may arise resulting in inefficient care and patient harm. Design thinking, a human-centered design method, represents a unique framework to support the planning, testing, and evaluation of new clinical spaces throughout all phases of construction. Healthcare simulation has been used to test new clinical spaces, yet most report using simulation only in the late design stages. Moreover, healthcare design models have potentially underused human factors approaches calling for human-centered design. We applied a multimodal simulation-based approach underpinned by the principles of design thinking throughout the planning and construction stages of a newly renovated academic emergency department. METHODS: A multidisciplinary team developed and integrated 3 simulation strategies (table-top, mock-up, and in situ simulation) into the 5-step process of design thinking. Through end-user engagement, we identified potential challenges, prototyped solutions through table-top and mock-up simulations, and iteratively tested these solutions through in situ simulation within the actual clinical space. RESULTS: The team used end-user engagement and feedback to brainstorm and implement effective solutions to problems encountered before opening the new emergency department. The iterative steps and targeted use of simulation resulted in redesigning departmental processes and actual clinical space while mitigating anticipated safety threats and departmental deficiencies. CONCLUSIONS: Design thinking coupled with multimodal simulation across all phases of construction enhanced the design and testing of new clinical infrastructure. Applying this approach early, thoroughly, and efficiently will help healthcare organizations plan changes to clinical spaces.

'There shouldn't be anything wrong with not knowing': epistemologies in simulation.

CONTEXT: Medical education embraces simulation-based education (SBE). However, key SBE features purported to support learning, such as learner safety and learning through experience and error, may not align with the dominant culture of medicine, in which portraying confidence and certainty about one's knowledge prevails. Misaligned conceptions about knowledge and learning may produce unintended negative effects, including the suboptimal implementation of SBE, which could consequently compromise SBE and its outcomes. METHODS: To uncover the epistemological beliefs of students experiencing SBE, we conducted a theory-informed analysis of interviews with 24 pre-clerkship medical students following their participation in an SBE training study. Our analysis borrowed from coding methods common in constructivist grounded theory and used Hofer and Pintrich's four dimensions of epistemology as sensitising concepts. RESULTS: Participants subscribed to a dominant view of knowledge as consisting of concrete facts, derived from external sources. By contrast, they described but did not prioritise a conception of building their own knowledge through different learning experiences. Participants positioned experts (i.e. teaching faculty members) as the ultimate knowledge validators through their presence and feedback. Participants also noted that faculty staff could counter medicine's pressures to perform with certainty and confidence at all times by instead embodying and modelling an authentic appreciation of learning through experiences, errors and discovery. CONCLUSIONS: Medicine's tendency to idealise the objective pursuit of singular truths may compromise the purported culture of SBE as a space for learning many wide-ranging aspects of medicine, including how and when to innovate and deviate from norms. Explicit attempts to bridge the epistemological beliefs of medicine and SBE may better enable the realisation of safe experiential learning. Faculty members are positioned to play key roles in enabling this bridging.