Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit.
OBJECTIVE
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.
Department of Thoracic Surgery, Royal Devon and Exeter NHS Foundation Trust, Devon, UK. richard.berrisford@nhs.net
Richard G
RG
Berrisford
Iain H
IH
Wilson
Mike
M
Davidge
David
D
Sanders
D057189:Checklist; D004739:England; D005246:Feedback; D019983:Guideline Adherence; D006801:Humans; D008485:Medical Audit; D019300:Medical Errors / Q000145:classification / Q000517:prevention & control; D010348:Patient Care Team / Q000458:organization & administration; D011446:Prospective Studies; D017751:Safety Management / Q000458:organization & administration; D019616:Thoracic Surgical Procedures / Q000009:adverse effects*; D054556:Venous Thromboembolism / Q000209:etiology / Q000517:prevention & control*