PMID- 29435508
OWN - NLM
STAT- PubMed-not-MEDLINE
LR  - 20220314
IS  - 2399-6641 (Electronic)
IS  - 2399-6641 (Linking)
VI  - 6
IP  - 2
DP  - 2017
TI  - An easy, prompt and reproducible methodology to manage an unexpected increase of 
      incident reports in surgery theatres.
PG  - e000147
LID - 10.1136/bmjoq-2017-000147 [doi]
LID - e000147
AB  - OBJECTIVES: Surgery is a high-risk hospital area for adverse events (AEs) 
      occurrence. This study aims to develop an effectiveness and reactive methodology 
      to manage an unexpected increase of AEs in the operating rooms (ORs) of a large 
      Academic Hospital providing about 30 000 surgeries per year. METHODS: The study 
      included three phases: 1. analysis of the AEs collected through the hospital 
      incident reporting system from 2014 to 2015; 2. development of a programme to 
      improve the surgical patient's safety and 3. application and evaluation of the 
      programme effectiveness. RESULTS: In 2014, all hospital AEs were 825 (10.3% in 
      ORs), while in the first 5 months of 2015, they were 645 (17.7% in ORs) [relative 
      risk (RR) 2015 vs 2014=1.7; 95% CI=1.3 to 2.2; p<0.0001] with two sentinel 
      events. Due to this increase, 177 real-time observations were planned in 12 ORs 
      with external staff (n.25) during 1 week in June, July and November 2015 using a 
      checklist with 14 items related to the patient's pathway (surgical site, 
      time-out, medical records and sponges count). After the observations, the AEs 
      decreased from 11.4x1000 surgeries (January-June 2015) to 8.6x1000 (July-December 
      2015) (RR=0.7, 95% CI=0.6 to 0.9, p<0.05). Compliance to the correct procedures 
      applied by ORs staff has improved during the year for all items. CONCLUSIONS: The 
      methodology of this study has been revealed effective to control an unexpected 
      increase in AEs and to improve the healthcare workers' adherence to correct 
      procedures and it could be translated in other patients' safety settings.
FAU - Moccia, Adriana
AU  - Moccia A
AUID- ORCID: 0000-0002-7899-9788
AD  - Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.
FAU - Quattrin, Rosanna
AU  - Quattrin R
AD  - Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.
FAU - Battistella, Claudio
AU  - Battistella C
AD  - Department of Medicine, Universita degli Studi di Udine, Udine, Italy.
FAU - Fabbro, Elisa
AU  - Fabbro E
AD  - Department of Medicine, Universita degli Studi di Udine, Udine, Italy.
FAU - Brusaferro, Silvio
AU  - Brusaferro S
AD  - Department of Medicine, Universita degli Studi di Udine, Udine, Italy.
LA  - eng
PT  - Journal Article
DEP - 20171120
PL  - England
TA  - BMJ Open Qual
JT  - BMJ open quality
JID - 101710381
PMC - PMC5717955
OTO - NOTNLM
OT  - adverse events
OT  - operating rooms
OT  - real-time observations
COIS- Competing interests: None declared.
EDAT- 2018/02/13 06:00
MHDA- 2018/02/13 06:01
PMCR- 2017/11/20
CRDT- 2018/02/14 06:00
PHST- 2017/06/28 00:00 [received]
PHST- 2017/10/07 00:00 [revised]
PHST- 2017/10/09 00:00 [accepted]
PHST- 2018/02/14 06:00 [entrez]
PHST- 2018/02/13 06:00 [pubmed]
PHST- 2018/02/13 06:01 [medline]
PHST- 2017/11/20 00:00 [pmc-release]
AID - bmjoq-2017-000147 [pii]
AID - 10.1136/bmjoq-2017-000147 [doi]
PST - epublish
SO  - BMJ Open Qual. 2017 Nov 20;6(2):e000147. doi: 10.1136/bmjoq-2017-000147. 
      eCollection 2017.