Ward round documentation in a major trauma centre: can we improve patient safety?

Abstract

Our objective was to improve documentation and patient safety in a major trauma centre.A retrospective audit was undertaken in March 2014. Ward round entries for each orthopaedic patients on three dates were assessed against standards and analysed. The audit was repeated in April 2014, and again in August 2014.Thorough documentation is paramount in a major trauma centre. It forms a useful record of the patients hospital stay, is a legal document and is highlighted in national guidelines. It provides a basis for good handover, ensuring continuation of care and maintaining patient safety. Resultant poor compliance with Royal College guidelines in the initial audit led to the production of a new electronic based note keeping system. A meeting was held with all staff prior to introduction.Our initial results gained 75 entries, and none showed full compliance. Mean compliance per entry was 59% (0–81%). The second attempt gained 90 entries, with 30 from the weekend. Mean compliance per entry 97%. Third attempt received 61 entries, with 27 from the weekend. Mean compliance was 96%, meaning that the improvement was being maintained.Recent distressing reports regarding patient highlighted the importance of patient. Our initial audit proved there were many areas lacking in our documentation and improvement was necessary. Prior to introducing electronic systems, the implemented change has produced improvement in documentation, and provides a useful handover tool for staff.

Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital.

“…Additionally there is time and resource pressures on secretarial support for typing operative notes which affect the timely production of typed notes and increase the potential costs to the trust. There have been a number of quality improvement projects that have utilised the use of electronic templates [4][5][6] although none have developed a sustainable, integrated, and comprehensive electronic operative notes template.…”

Comparison of Digital Versus Conventional Documentation of Ward Round in Terms of Staff Satisfaction, Effect on Education, and Adherence to British Orthopaedic Association Guidelines

“…compared to the second cycle (P=0.203) [17]. Our study showed that BOA guidelines can be followed more easily by electronic methods than paper-based and have showed significant improvement in ward round documentation.…”

Improving Thoracic Surgery Ward Round Quality and Enhancing Patient Safety in a referral centre

“…Based on the bene ts of systematic ward rounds and checklists presented by previous research (19,20) and compliantly with national standards we have developed a ward round note that includes all mandatory information for daily patient review. Further research should explore the impact of this new documentation method on patient care and postoperative outcomes.…”