Thesis (M.Med.(Orthopaedic Surgery))--University of the Witwatersrand, Faculty of Health Sciences, 2013

Lisenda, Laughter

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  The effect of a surgical safety checklist on mortality, morbidity and cancellation.   Laughter Lisenda MB ChB BAO (NUIGalway), MRCS (Ire) Student number: 573636   Supervisor: Professor Mkhululi Lukhele MBChB, MMed(Orth), FCS(Orth)SA Professor and Head of Orthopaedics, University of the Witwatersrand   Original research submitted as partial fulfillment of the requirements for the Masters in Medicine degree in Orthopaedic Surgery at the  University of the Witwatersrand, Johannesburg.                                              18th November 2013.                                                                          II  Declaration                                                                                                                                                                                                                                                        I  Laughter Lisenda do hereby declare that this report is my own work. It is being submitted for the degree of Master in Medicine (Orthopaedics) at the University of the Witwatersrand, Johannesburg and it has never been submitted for any exam at this or any other University.  Ethics clearance was granted by the ethics committee of the University of the Witwatersrand. (Appendix 1 and 2).                                                                                                      Laughter Lisenda 18th November 2013 III  Acknowledgements  I owe my deepest gratitude to my supervisor and departmental head Professor Mkhululi Lukhele whose encouragement, guidance and support from the initial to the final stage enabled me to develop an understanding of this research topic.  I would also like to thank Professor Anthony Robertson who helped with the compilation of the checklist and making sure that all the departmental units had enough stock.  I offer my regards and thanks to my fellow registrars, junior colleagues and secretarial staff who supported me during the completion of the project.  Lastly, I would like to thank the University of the Witwatersrand and the Charlotte Maxeke Johannesburg Academic Hospital for allowing me to conduct the research in their institutions.  Laughter Lisenda    IV  Abstract Introduction: Surgical complications are common and most of them are preventable, especially if one considers that 53% to 70% of surgical errors occur outside theatre. Recent studies have shown that pre-operative checklists are associated with improved patient outcome. We hypothesize that in our institution there will be an improvement in patient outcome if a safety checklist is introduced.  Method: A modified multidisciplinary WHO safety checklist was introduced at our institution on the 1st March 2011. The primary focus was on elective patients admitted in all the units of the division of orthopaedic surgery. We retrospectively collected data from the daily morbidity and mortality (MM) reports presented by the different units from the 1st January to 29th February 2011 (2 months). In addition a pre-induction survey was filled in by all registrars. The same survey was given to the same registrars for assessment at the end of the 2 months of post-implementation in June 2011. Results: The mortality rate decreased by 0.7% (from 1.5% to 0.8%) after the introduction of a surgical safety checklist. There was also a 0.8% reduction V  in avoidable morbidity (from 1.9% to 1.1%) and a 1.6% reduction in avoidable cancellation (from 2.3% to 0.7%). Only 77% of registrars acknowledged undertaking pre-operative planning prior to implementation of the checklist compared with 87.5% post implementation. Conclusion: The implementation of the modified WHO safety check list was associated with some reduction in cancellations, avoidable morbidity and mortality. The downward trend suggests that the safety checklist would be a beneficial practice in our setting. Recommendation: Surgical safety checklists should be regarded as a standard practice for all orthopaedic procedures in order to decrease complications, especially in high operation volume and training centers.     VI  Table of contents Title I Declaration II Acknowledgements III Abstract IV Table of contents VI List of tables, graphs and figures VIII List of abbreviations IX  Chapter 1 - Introduction and Literature review 1 Definition and Epidemiology 1 Classification 2 WHO Checklist 4  Chapter 2 - Research Question 9 Background 9 Hypothesis 9 Aim/ Objectives 10 Significance 10  Chapter 3 – Study design and methodology 11 Study design 11 Statistical analysis 11 Intervention 11 VII  Inclusion criteria 12 Exclusion criteria 12  Chapter 4 – Results 13  Chapter 5 – Discussion 21  Chapter 6 – Conclusion and recommendation 25  References 26  Appendix 1 Initial Ethics approval 30  Appendix 2 Revised title document 31  Appendix 3 CEO Approval letter 33  Appendix 4 Pre-operative checklist document 34- 37  Appendix 5 Registrars’ survey document 38 VIII  List of Tables, Graphs and Figures                                                                                                                                           Table 1: Clavien-Dindo grading system for the classification of surgical   complications 3 Table 2: Summary of the division of orthopaedics 13 Table 3: Summary of the activities of each clinical unit 14 Table 4: Breakdown of morbidity cases 16 Table 5:  Summary of the causes of cancellation 18  Graph 1: Breakdown of mortality cases 15 Graph 2: Breakdown of avoidable morbidity cases 17 Graph 3: Survey of the orthopaedic registrars at Witwatersrand Orthopaedic Circuit pre-implementation and post-implementation of a surgical safety checklist 20  Figure 1: Total of pre-implementation and post-implementation avoidable cancellations 19        IX  List of abbreviations  WHO - World Health Organization MM - Mortality and Morbidity DVT - Deep Venous Thrombosis ICD - International statistical classification of diseases and related health problems ASA - American Society of Anaesthesiologists (ASA) Score SURPASS SURgical PAtient Safety System (SURPASS) checklist                

The effects of a surgical safety checklist on mortality, morbidity and cancellation

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