20 Improving operation note standards. (12th November 2018)

• Record Type: Journal Article
• Authors: Shah, Sachi Vinodkumar; Ebied, Husam
• Is Part Of: BMJ leader. Volume 2(2018)Supplement 1
• Page Start: A8
• Page End: A8
• Publication Date: 2018-11-12
• Subjects: Medical personnel -- Periodicals; Leadership -- Periodicals; Medicine -- Practice -- Management -- Periodicals; Health services administration -- Periodicals; 610.68
• DOI: 10.1136/leader-2018-FMLM.20
• Languages: English
• ISSNs: 2398-631X

Abstract

Abstract : Background: High standards of operation notes that are accurate, comprehensive and legible are essential for continuity of care. St Thomas' hospital uses an almost fully electronic system for patient records. However, operation notes are hand written onto blank paper. They often lack sufficient detail, posing a threat to patient safety. Aims: The Royal College of Surgeons England (RCSEng) defines an 18-point criteria that should be included in an operation note. The aim was to assess and improve compliance of operation notes at St Thomas' hospital with the RCSEng guidelines. Methods and intervention: A retrospective review of operation notes of laparoscopic appendicectomies was conducted over a 3 month period from June 2017 – September 2017. A proforma was designed to include the RCSEng criteria. This involved several meetings with consultant surgeons. A second audit cycle was conducted on all proformas used during a 3 month period from February 2018 – April 2018. Results: A total of 75 operation notes were reviewed. Proforma use showed a statistically significant increase in average compliance from 51% to 98.9%(p<0.0001). There was at least 90% compliance in all 18 criteria and 10 out of 18 criteria showed statistically significant increase. Discussion: This is the first standardised operation note in the department. Liaison with the School of Improvement and IT services is allowing the template to be modified into an electronic proforma which can be used for all surgical procedures. Excellent leadership and negotiation allowed an 'easy' yet unsafe system to be improved with approval of consultants. Conclusion: Junior doctors often encounter system failures first-hand which can directly affect patient care. There is a general assumption that innovation is governed at a higher level. With good leadership and communication from junior doctors, a simple idea can be built up to a larger scale with a significant impact on patient safety.