A dermatology surgical safety checklist: an objective resident performance tool
This article is corrected by:
- Errata: Erratum Volume 52, Issue 12, 1626, Article first published online: 21 November 2013
Funding sources: None.
Conflicts of interest: None.
Stephanie Diamond, md
Department of Dermatology
Wayne State University
18100 Oakwood Boulevard, Suite 300
Dearborn, MI 48124, USA
The initiation of protocols for ensuring surgical safety is relevant to improving patient care and maximizing provider safety. A review of the recent literature demonstrates a need in dermatology for patient safety studies. Inpatient studies have established a foundation for the application of systems-based changes that can improve patient safety. A more standardized approach to procedures has been studied extensively in the inpatient literature. With the advent of the World Health Organization (WHO) Surgical Safety Checklist, it is clear that checklists can have a significant impact on reducing surgical morbidity and mortality.[3, 4] Inpatient studies have shown surgical safety checklists can save money and help prevent malpractice claims.[5, 6]
Many inpatient specialties have successfully implemented specialty-specific checklists in the USA and elsewhere.[7, 8] Dermatology has yet to adopt a formalized surgical checklist for outpatient procedures, although anecdotal evidence suggests providers utilize original unpublished checklists. This primarily reflects a lack of studies on the necessity for such checklists in the outpatient setting, in which many of the procedures performed carry lower levels of risk for morbidity and mortality than do inpatient procedures. However, infection rates following outpatient dermatology surgery range from 2% to 5%, and infection rates in inpatient biopsy procedures can be as high as 29%.[9, 10] The loss of specimens represents an additional complication: one outpatient procedural study (in plastic surgery) cited an incidence of specimen loss of one in 1466 (0.068%) in routine skin biopsies.
The incorporation of patient safety measures has been embraced by medical education, but formalized dermatology-specific residency and medical education initiatives are lacking.[12, 13] Patient safety initiatives are particularly relevant to dermatology residents as it is during residency that important surgical safety measures will be permanently incorporated into a physician's day-to-day practice. Not only have these measures been shown to improve patient safety, but they are based on techniques pertaining to behaviors such as the disposal of sharps that enhance the safety of the entire healthcare service team.
Materials and methods
Our institutional review board approved the study of 11 dermatology residents. The residents were individually asked to perform a simulated punch biopsy while being visually recorded on a hand-held device (iPhone 4 with 5-megapixel iSight camera; video recording, high definition [720 pixels] up to 30 frames per second with audio). The residents were asked to perform the procedure just as they normally would in a real patient setting and to simulate the presence of a patient. They were assured that no information would be permanently linked to them and that the videos of the procedure would be deleted by themselves following completion of the task. When they had completed the simulated biopsy, the residents were given the checklist shown in Table 1. This original checklist was developed utilizing a compilation of checklists published in the literature. A total of 21 safety measures were assessed using a point system, and a final total of 42 points represented a perfect score. An option of “not applicable” for zero points was included in order to not artificially lower a resident's score if he or she felt a measure was not needed. The residents viewed themselves performing the procedure and evaluated themselves using the checklist. The activity was repeated two weeks later, again utilizing the checklist.
Table 1. The checklist and scoring system used in the current study
|Electrocautery risk factors addressed||2||1||−1||0|
|Informed consent obtained||2||1||−1||0|
|Preoperative pathology reviewed||2||1||−1||0|
|Site identified and marked||2||1||−1||0|
|Specimen labeling confirmed||2||1||−1||0|
|Put on protective gear||2||1||−1||0|
|Medication administered verified||2||1||−1||0|
|Sterilize or clean the area||2||1||−1||0|
|Time out done||2||1||−1||0|
|Placement of sterile drapes||2||1||−1||0|
|Maintenance of sterile or clean field||2||1||−1||0|
|Disposal of sharps (no recapping)||2||1||−1||0|
|Specimen confirmed in container||2||1||−1||0|
|Postoperative wound instructions given||2||1||−1||0|
|Pathology paperwork filled out||2||1||−1||0|
Scores during week 1 ranged from 9 to 28 of a total of 34 to 40 possible points; each resident made at least one “not applicable” selection. The average total point score was 17, and the average percentage score was 46%. Two weeks later, when the same activity was performed, scores ranged from 19 to 37 of a total of 36 to 42; the average total point score was 30, and the average percentage score was 74%. All residents reported improved total points, and most showed an overall improved percentage. Three residents demonstrated improved total points and a decreased percentage because their selection of the “not applicable” options differed between tests. Table 2 illustrates demographic and performance data.
Table 2. Demographic and performance data for the 11 residents participating in the present study (three men, eight women)
|3||22/36 (61)||24/42 (57)||+2||−4|
|3||20/38 (53)||30/36 (83)||+10||+30|
|3||9/38 (24)||26/38 (68)||+17||+44|
|2||16/40 (40)||30/38 (79)||+14||+39|
|2||18/38 (47)||37/40 (92)||+19||+5|
|2||16/34 (47)||19/42 (45)||+3||−2|
|2||11/38 (29)||22/42 (52)||+11||+3|
|1||20/40 (50)||35/42 (83)||+15||+3|
|1||28/38 (74)||29/42 (69)||+1||−5|
|1||19/38 (50)||37/38 (97)||+18||+47|
|1||13/40 (33)||37/42 (88)||+24||+55|
|Test 1||17 (9–22)||15 (11–18)||20 (13–28)|
|Test 2||27 (24–30)||27 (19–37)||34 (29–37)|
|Overall score in test 1, mean (range)||17 (9–28)|| |
|Overall score in test 2, mean (range)||30 (19–37)|| |
During test 1, the top three missed relevant measures were “medications reviewed”, missed by eight residents, “verify allergies”, missed by eight residents, and “pathology paperwork filled out”, missed by seven residents. Following the intervention, the top two missed measures were “disposal of sharps”, missed by five residents, and “placement of sterile drapes”, missed by four residents.
Several safety measures were marked as “not applicable”. During test 1, “placement of sterile drapes” was considered to be “not applicable” by nine residents. At the subsequent procedure, “preoperative pathology reviewed” represented the item for which the “not applicable” option was most commonly chosen, with three residents choosing this box. One very significant parameter, “hand washing”, was missed by six residents in the first test and subsequently by two residents.
There was no obvious difference in scores according to residency year; however, the lowest score in test 1 was seen in the senior resident grouping, and the highest scores at follow-up were seen in the junior resident groupings. Because of the small sample size, a more detailed statistical analysis was not performed. The timing of each resident's performance was not noted during either of the simulated biopsies.
This was a single-institution, small study that relied on self-evaluation and a simulated procedure. Resident feedback indicated that the artificial nature of the procedure caused certain components, such as hand washing, to be more easily missed. Other safety measures, such as the confirmation of the patient's immune status/infection (for human immunodeficiency virus [HIV] infection, etc.), as well as the preoperative recording of clinical images for site localization and documentation, represent important steps that were not represented on the original checklist. Although the residents were asked not to discuss the study amongst themselves until it had been completed, this was not strictly enforced. Although data from other specialties imply that this surgical intervention would have similar impacts on patient morbidity and mortality, studies in the dermatology setting have yet to be performed.
This is the first study to propose the use of a dermatology surgical safety checklist in residency training. We have illustrated that there are deficiencies in both the practice of surgical safety measures and in the institution of these measures in a standardized fashion during residency. The range of scores across years of resident training highlights the need for early incorporation of a procedure during residency training before habits become more firmly established. Patient safety, as well as public perceptions of safety during outpatient surgery, is important in maintaining the domain of dermatologic outpatient surgery. Recent studies have shown dermatology outpatient surgery to be very safe. It is important, however, to continue to examine how patient and provider safety can be improved. Further larger studies involving multiple institutions, as well as a prospective, blinded, real-world study, utilizing the proposed dermatology surgical checklist should be encouraged. Adding additional safety measures to the checklist such as those pertaining to immune status and clinical images would be appropriate to maximize both patient and provider safety. The proposed checklist could be used in residency programs in an important objective structured clinical examination. The use of this checklist during each year of residency might also represent an objective measure of clinical performance for the purpose of resident evaluation. Although many established professionals might be hesitant to incorporate the use of a formal checklist that many providers already implement mentally, this tool could help residents and program directors to become more aware of resident success and areas in need of improvement. The incorporation of a formal measure such as the proposed checklist might even function as a performance measure outcome to be applied in future assessments for insurance reimbursements and medical liability claims.