Evaluating the SAFE Tool’s Impact on Documentation and Patient Safety During Structured Ward Rounds in General Surgery: A Retrospective Study

• Published in: Curēus (Palo Alto, CA) Vol. 16; no. 11
• Main Authors: Atluri, Lakshmi Malvika, Chong, Kenneth Jit, Zumot, Maya, Kantamaneni, Ketan, Kondi, Suresh, Bakka, Havil Stephen Alexander, Kantamneni, Reshmitha
• Format: Journal Article
• Language: English
• Published: Palo Alto (CA) Cureus 16.11.2024
• Subjects: General Surgery; Quality Improvement
• ISSN: 2168-8184; 2168-8184
• DOI: 10.7759/cureus.73823

Aim  Effective documentation of critical clinical information is vital for patient safety and timely discharges. Ward rounds (WRs) are crucial for multidisciplinary assessments and care planning. Current emergency surgical WR documentation is inconsistent; therefore, this study will implement a structured WR template adapted from the Royal College of Surgeons of Edinburgh’s “Surgical Assessment for Emergencies Ward Round Tool” (SAFE) to address these shortcomings. Methods  A retrospective review of case note entries from surgical WRs was conducted between April 1 and April 14, 2024. A total of 500 random WR entries were reviewed. Recommended standards of WR documentation were obtained from the SAFE tool. The overall documentation of 14 parameters was checked. The WR entries from the weekends have been excluded from the study. After the implementation of the template, another review of 500 case note entries was conducted between October 1 and October 14, 2024. Results  The only consistently documented parameter is the name of the consultant (97%). Parameters such as VTE prophylaxis (5%), examination findings (18%), NBM/nutrition (20%), the patient’s current clinical status (30%), and NEWS/observations (35%) were very suboptimally documented. Management plans and discharge planning were not efficiently detailed (<30%). All the parameters that were reviewed post-implementation of a WR template were documented, with the average being 88.14%, thus demonstrating a significantly high impact. Conclusion  A modifiable documentation template was created to improve and standardize the General Surgery WR documentation. The implementation of a WR template has enhanced the documenting of essential elements of patient care. It enhances patient safety as well as communication and documentation, ensuring that critical issues are not overlooked during patient assessments on WRs.