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• "Driven to distraction" and driving for excellence in ward round practice
  Philip H. Pucher
  Published on: 13 May 2016

• Published on: 13 May 2016

  "Driven to distraction" and driving for excellence in ward round practice

  • Philip H. Pucher, Honorary Clinical Lecturer
  • Other Contributors:
    • Rajesh Aggarwal

  Dear Sir, It is with great interest that we read the recent publication by Thomas and colleagues investigating ward-based patient care.1 They describe a study in which 28 medical students were randomised to either control (no intervention) or intervention (performance feedback and error management training) groups, performing simulated ward rounds complicated by environmental distractors. Significant reductions in errors were se...

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  Dear Sir, It is with great interest that we read the recent publication by Thomas and colleagues investigating ward-based patient care.1 They describe a study in which 28 medical students were randomised to either control (no intervention) or intervention (performance feedback and error management training) groups, performing simulated ward rounds complicated by environmental distractors. Significant reductions in errors were seen in both groups from the first to the second ward round, with a significantly greater reduction seen in the intervention group. We thoroughly commend on their efforts to add to the body of literature for what is such a crucial, but until now has been a sparsely investigated, area of care. There can be no doubt that in current practice, the conduct of ward rounds may be hugely variable,2, 3 with significant implications for patient outcomes.2 In surgical literature, the phenomenon of "failure to rescue" describes failures in ward-based management of complications, which represent a major source of variability in surgical outcomes, emphasising the need to focus on ward rounds to improve outcomes.4 Future research in this area must be robust, evidence-based, and ideally tied to clinically relevant subjects and outcomes. With this in mind, we would like to raise several questions in reference to the study by Thomas et al. How were the "distractors" selected? Loud radio noises and upset relatives would appear to represent fairly arbitrary factors with unclear relevance to clinical care. Additionally, the authors appear to suggest that the intervention included very specific feedback on how to cope with these distractors - if part of the scoring is to assess whether the radio was turned off, and the intervention includes instruction to do so, can the result be truly deemed valid? Finally, was there a reason for selecting medical students rather than a more valid population of clinical staff such as house officers, or even residents, who are commonly responsible for the ward round? Recently, we have described the Surgical Ward-care Assessment Tool (SWAT), a checklist-based tool for technical skills, and the Ward-based Non-Technical Skills score (W-NOTECHS), a Likert-based tool for non-technical skills; together these represent objective, validated scoring scales for ward round performance.5 It is possible that the adaptation of such surgical rating scales to address other specialty populations may present an effective way forward. We are fully in agreement with Thomas and colleagues in their statement that to move ward round initiatives forward, we must in future focus on changing patient safety behaviours. Thus, future assessments of ward round performance must focus on objective assessment metrics which are generalisable across studies, contexts, and specialties. Only in this manner can reliable, reproducible interventions be developed to standardise and improve care and outcomes. References 1. Thomas I, Nicol L, Regan L, et al. Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students. BMJ Qual Saf 2014. 2. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014; 259:222-6. 3. Blucher KM, Dal Pra SE, Hogan J, Wysocki AP. Ward safety checklist in the acute surgical unit. ANZ J Surg 2013. 4. Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992; 30:615-29. 5. Pucher PH, Aggarwal R, Srisatkunam T, Darzi A. Validation of the Simulated Ward Environment for Assessment of Ward-Based Surgical Care. Ann Surg 2014; 259:215-21.

  Conflict of Interest:

  Rajesh Aggarwal is a consultant for Applied Medical. No other competing interests declared.

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  Conflict of Interest:
  None declared.

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