170 results for Merry, Alan

  • Awareness during general anaesthesia in the first 4,000 incidents reported to webAIRS

    Leslie, K; Culwick, MD; Reynolds, H; Hannam, JA; Merry, Alan (2017-07)

    Journal article
    The University of Auckland Library

    The aim of this study was to analyse the incidents related to awareness during general anaesthesia in the first 4,000 cases reported to webAIRS-an anaesthetic incident reporting system established in Australia and New Zealand in 2009. Included incidents were those in which the reporter selected "neurological" as the main category and "awareness/dreaming/nightmares" as a subcategory, those where the narrative report included the word "awareness" and those identified by the authors as possibly relevant to awareness. Sixty-one awareness-related incidents were analysed: 16 were classified as "awareness", 31 were classified as "no awareness but increased risk of awareness" and 14 were classified as "no awareness and no increased risk of awareness". Among 47 incidents in the former two categories, 42 (89%) were associated with low anaesthetic delivery and 24 (51%) were associated with signs of intraoperative wakefulness. Memory of intraoperative events caused significant ongoing distress for five of the 16 awareness patients. Patients continue to be put at risk of awareness by a range of well-described errors (such as syringe swaps) but also by some new errors related to recently introduced anaesthetic equipment, such as electronic anaesthesia workstations.

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  • Incorrect representation of aseptic techniques

    Merry, Alan; Gargiulo, Derryn; Sheridan, Jane; Webster, Craig; Swift, Simon; Torrie, Jocelyn; Weller, Jennifer; Henderson, K; Sturge, Jacqueline (2017-05)

    Journal article
    The University of Auckland Library

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  • Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention

    Haynes, AB; Weiser, TG; Berry, WR; Lipsitz, SR; Breizat, A-HS; Dellinger, EP; Dziekan, G; Herbosa, T; Kibatala, PL; Lapitan, MCM; Merry, Alan; Reznick, RK; Taylor, B; Vats, A; Gawande, AA (2011-01-01)

    Journal article
    The University of Auckland Library

    OBJECTIVES: To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention. DESIGN: Pre- and post intervention survey. SETTING: Eight hospitals participating in a trial of a WHO surgical safety checklist. PARTICIPANTS: Clinicians actively working in the designated study operating rooms at the eight hospitals. SURVEY INSTRUMENT: Modified operating-room version Safety Attitudes Questionnaire (SAQ). MAIN OUTCOME MEASURES: Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability. RESULTS: Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation. CONCLUSIONS: Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.

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  • A framework of comfort for practice: an integrative review identifying the multiple influences on patients??? experience of comfort in healthcare settings.

    Wensley, Cynthia; Botti, M; McKillop, Ann; Merry, Alan (2017)

    Journal article
    The University of Auckland Library

    Comfort is central to patient experience but the concept of comfort is poorly defined. This review aims to develop a framework representing patients' complex perspective of comfort to inform practice and guide initiatives to improve the quality of healthcare.CINAHL, MEDLINE Complete, PsycINFO and Google Scholar (November 2016); reference lists of included publications.Qualitative and theoretical studies advancing knowledge about the concept of comfort in healthcare settings. Studies rated for methodological quality and relevance to patients' perspectives.Data on design, methods, features of the concept of comfort, influences on patients' comfort. Data were systematically coded and categorized using Framework method.Sixty-two studies (14 theoretical and 48 qualitative) were included. Qualitative studies explored patient and staff perspectives in varying healthcare settings including hospice, emergency departments, paediatric, medical and surgical wards and residential care for the elderly. From patients' perspective, comfort is multidimensional, characterized by relief from physical discomfort and feeling positive and strengthened in one's ability to cope with the challenges of illness, injury and disability. Different factors are important to different individuals. We identified 10 areas of influence within four interrelated levels: patients' use of self-comforting strategies; family presence; staff actions and behaviours; and environmental factors.Our data provide new insights into the nature of comfort as a highly personal and contextual experience influenced in different individuals by different factors that we have classified into a framework to guide practice and quality improvement initiatives.

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  • A cross-sectional overview of the first 4,000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand

    Gibbs, NM; Culwick, M; Merry, Alan (2017)

    Journal article
    The University of Auckland Library

    webAIRS is a web-based de-identified anaesthesia incident reporting system, which was introduced in Australia and New Zealand in September 2009. By July 2016, 4,000 incident reports had been received. The incidents covered a wide range of patient age (90 years), American Society of Anesthesiologists physical status, and body mass index (50 kg/m2). They occurred across a wide range of anaesthesia techniques and grade of anaesthesia provider, and over a wide range of anaesthetising locations and times of day. In a high proportion the outcome was not benign; about 26% of incidents were associated with patient harm and a further 4% with death. Incidents appeared to be an ever-present risk in anaesthetic practice, with extrapolated estimates exceeding 200 per week across Australia and New Zealand. Independent of outcomes, many anaesthesia incidents were associated with increased use of health resources. The four most common main categories of incident were Respiratory/Airway, Medication, Cardiovascular, and Medical Device/Equipment. Over 50% of incidents were considered preventable. The narratives accompanying each incident provide a rich source of information, which will be analysed in subsequent reports on particular incident types. The summary data in this initial overview are a sober reminder of the prevalence and unpredictability of anaesthesia incidents, and their potential morbidity and mortality. The data justify current efforts to better prevent and manage anaesthesia incidents in Australia and New Zealand, and identify areas in which increased resources or additional initiatives may be required.

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  • Applying ethical and legal principles to new technology: the University of Auckland Faculty of Medical and Health Sciences??? policy ???Taking and Sharing Images of Patients???

    Jonas, Monique; Malpas, Phillipa; Kersey, K; Merry, Alan; Bagg, Warwick (2017-01-27)

    Journal article
    The University of Auckland Library

    To develop a policy governing the taking and sharing of photographic and radiological images by medical students.The Rules of the Health Information Privacy Code 1994 and the Code of Health and Disability Services Consumers' Rights were applied to the taking, storing and sharing of photographic and radiological images by medical students. Stakeholders, including clinicians, medical students, lawyers at district health boards in the Auckland region, the Office of the Privacy Commissioner and the Health and Disability Commissioner were consulted and their recommendations incorporated.The policy 'Taking and Sharing Images of Patients' sets expectations of students in relation to: photographs taken for the purpose of providing care; photographs taken for educational or professional practice purposes and photographic or radiological images used for educational or professional practice purposes. In addition, it prohibits students from uploading images of patients onto image-sharing apps such as Figure 1. The policy has since been extended to apply to all students at the Faculty of Medical and Health Sciences at the University of Auckland.Technology-driven evolutions in practice necessitate regular review to ensure compliance with existing legal regulations and ethical frameworks. This policy offers a starting point for healthcare providers to review their own policies and practice, with a view to ensuring that patients' trust in the treatment that their health information receives is upheld.

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  • Forcing functions and their consequences

    Webster, Craig; Merry, Alan (2017-02)

    Journal article
    The University of Auckland Library

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  • Retesting the Hypothesis of a Clinical Randomized Controlled Trial in a Simulation Environment to Validate Anesthesia Simulation in Error Research (the VASER Study)

    Merry, Alan; Sturge, Jacqueline; Webster, Craig; Edwards, K-E; Torrie, Jocelyn; Frampton, C; Wheeler, DW; Gupta, AK; Mahajan, RP; Evley, R; Weller, Jennifer (2017-03)

    Journal article
    The University of Auckland Library

    Simulation has been used to investigate clinical questions in anesthesia, surgery, and related disciplines, but there are few data demonstrating that results apply to clinical settings. We asked "would results of a simulation-based study justify the same principal conclusions as those of a larger clinical study?"We compared results from a randomized controlled trial in a simulated environment involving 80 cases at three centers with those from a randomized controlled trial in a clinical environment involving 1,075 cases. In both studies, we compared conventional methods of anesthetic management with the use of a multimodal system (SAFERsleep; Safer Sleep LLC, Nashville, Tennessee) designed to reduce drug administration errors. Forty anesthesiologists each managed two simulated scenarios randomized to conventional methods or the new system. We compared the rate of error in drug administration or recording for the new system versus conventional methods in this simulated randomized controlled trial with that in the clinical randomized controlled trial (primary endpoint). Six experts were asked to indicate a clinically relevant effect size.In this simulated randomized controlled trial, mean (95% CI) rates of error per 100 administrations for the new system versus conventional groups were 6.0 (3.8 to 8.3) versus 11.6 (9.3 to 13.8; P = 0.001) compared with 9.1 (6.9 to 11.4) versus 11.6 (9.3 to 13.9) in the clinical randomized controlled trial (P = 0.045). A 10 to 30% change was considered clinically relevant. The mean (95% CI) difference in effect size was 27.0% (-7.6 to 61.6%).The results of our simulated randomized controlled trial justified the same primary conclusion as those of our larger clinical randomized controlled trial, but not a finding of equivalence in effect size.

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  • Student-led Intervention to InNOvate Hand Hygiene practice in Auckland Region???s Medical Students (The No HHARMS Study)

    Lucas, Nathanael; Hume, Carl; Al-Chanati, A; Diprose, W; Roberts, S; Freeman, J; Mogol, V; Hoskins, D; Hamblin, R; Frampton, C; Bagg, Warwick; Merry, Alan (2017-01-13)

    Journal article
    The University of Auckland Library

    BACKGROUND: Hand hygiene is important in reducing healthcare-associated infections. The World Health Organization has defined 'five moments' when hand hygiene compliance is required. During 2013, New Zealand national data showed poor compliance with these moments by medical students. AIM: To improve medical students' compliance with the five moments. METHODS: In this prospective student-led quality improvement initiative, student investigators developed, implemented and evaluated a multi-modal intervention comprising a three-month social media campaign, a competition and an entertaining educational video. Data on individual patient-medical student interactions were collected covertly by observers at baseline and at one week, six weeks and three months after initiation of the intervention. RESULTS: During the campaign, compliance improved in moment 2, but not significantly in moments 1, 3, 4 or 5. Statistical analysis of amalgamated data was limited by non-independent data points-a consideration apparently not always addressed in previous studies. CONCLUSIONS: The initiative produced improvements in compliance by medical students with one hand hygiene moment. Statistical analysis of amalgamated data for all five moments should allow for the non-independence of each occasion in which clinicians interact with a patient. More work is needed to ensure excellent hand hygiene practices of future doctors.

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  • Reducing harm from falls

    Jones, S; Blake, S; Hamblin, R; Petagna, C; Shuker, C; Merry, Alan (2016-12-02)

    Journal article
    The University of Auckland Library

    Serious adverse event reporting from district health boards (DHBs) brought in-hospital falls to the attention of the Health Quality & Safety Commission (the Commission) when it was incepted in 2010. In 2012, responding to the large numbers reported, the Commission began planning for a three-year programme to reduce harm from falls, initially to run 2013-2015. In this article we discuss the serious consequences of falls, and the challenges and practical considerations involved in reducing the risk of falling and the rate of falls. We explore the Commission's choice of an adaptive approach in its programme, and show how a targeted measurement framework and national action has led to a nationwide statistically significant reduction in fractured neck of femur (hip fracture) and associated costs resulting from in-hospital falls, from a median of 12 per 100,000 admissions to eight per 100,000 admissions, sustained as at June 2016 for six quarters. This reduction reflects nationwide implementation of two key care processes: 1.) the percentage of patients 75 and over provided with an assessment of their risk of falling upon admission to hospital has risen from 77% in the first quarter of 2013 to 91% nationally in June 2016, 2.) the percentage of those with identified risk who were provided with an individualised care plan that addressed those risks has risen from 77% of older patients in the first quarter of 2013 to 95% nationally in June 2016. (These results are also reflected in a 14% decrease to 30 June 2016 in numbers of falls reported by DHBs as serious adverse events). Finally, we give a call to arms to the disparate health practitioners and services across all settings for individualised responses to prevent falls one patient at a time, and for leadership responses that promote an integrated approach to falls in older people.

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  • A 'paperless' wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement

    Ong, APC; Devcich, Daniel; Sturge, Jacqueline; Lee, T; Merry, Alan; Mitchell, Simon (2016-12)

    Journal article
    The University of Auckland Library

    Outcome benefits of using the WHO Surgical Safety Checklist rely on compliance with checklist administration.To evaluate engagement of operating room (OR) subteams (anaesthesia, surgery and nursing), and compliance with administering checklist domains (Sign In, Time Out and Sign Out) and checklist items, after introducing a wall-mounted paperless checklist with migration of process leadership (Sign In, Time Out and Sign Out led by anaesthesia, surgery and nursing, respectively).This was a pre-post observational study in which 261 checklist domains in 111 operations were observed 2???months after changing the checklist administration paradigm. Compliance with administration of the checklist domains and individual checklist items was recorded, as was the number of OR subteams engaged. Comparison was made with 2013 data from the same OR suite prior to the paradigm change.Data are presented as 2013 versus the present study. The Sign In, Time Out and Sign Out domains were administered in 96% vs 98% (p=0.69), 99% vs 99% (p=1.00) and 22% vs 84% (p<0.001 for all comparisons).Improvements in team engagement and compliance with administering checklist items followed introduction of migrated leadership of checklist administration and a wall-mounted checklist. This paradigm change was relatively simple and inexpensive.

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  • Crisis in clinical care: an approach to management

    Runciman, WB; Merry, Alan (2005)

    Journal article
    The University of Auckland Library

    A "crisis" in health care is "the point in the course of a disease at which a decisive change occurs, leading either to recovery or to death". The daunting challenges faced by clinicians when confronted with a crisis are illustrated by a tragic case in which a teenage boy died after a minor surgical procedure. Crises are challenging for reasons which include: presentation with non-specific signs or symptoms, interaction of complex factors, progressive evolution, new situations, "revenge effects", inadequate assistance, and time constraints. In crises, clinicians often experience anxiety- and overload-induced performance degradation, tend to use "frequency gambling", run out of "rules" and have to work from first principles, and are prone to "confirmation bias". The effective management of crises requires formal training, usually simulator-based, and ideally in the inter-professional groups who will need to function as a team. "COVER ABCD-A SWIFT CHECK" is a pre-compiled algorithm which can be applied quickly and effectively to facilitate a systematic and effective response to the wide range of potentially lethal problems which may occur suddenly in anaesthesia. A set of 25 articles describing additional pre-compiled responses collated into a manual for the management of any crisis under anaesthesia has been published electronically as companion papers to this article. This approach to crisis management should be applied to other areas of clinical medicine as well as anaesthesia.

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  • Safety in medical simulation--overlooked or underappreciated?

    Merry, Alan; Wheeler, DW (2011-09)

    Journal article
    The University of Auckland Library

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  • Fake and expired medications in simulation-based education: an underappreciated risk to patient safety

    Torrie, Jocelyn; Cumin, David; Sheridan, Jane; Merry, Alan (2016-12)

    Journal article
    The University of Auckland Library

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  • Bow-tie diagrams for risk management in anaesthesia

    Culwick, MD; Merry, Alan; Clarke, DM; Taraporewalla, KJ; Gibbs, NM (2016-11)

    Journal article
    The University of Auckland Library

    Bow-tie analysis is a risk analysis and management tool that has been readily adopted into routine practice in many high reliability industries such as engineering, aviation and emergency services. However, it has received little exposure so far in healthcare. Nevertheless, its simplicity, versatility, and pictorial display may have benefits for the analysis of a range of healthcare risks, including complex and multiple risks and their interactions. Bow-tie diagrams are a combination of a fault tree and an event tree, which when combined take the shape of a bow tie. Central to bow-tie methodology is the concept of an undesired or 'Top Event', which occurs if a hazard progresses past all prevention controls. Top Events may also occasionally occur idiosyncratically. Irrespective of the cause of a Top Event, mitigation and recovery controls may influence the outcome. Hence the relationship of hazard to outcome can be viewed in one diagram along with possible causal sequences or accident trajectories. Potential uses for bow-tie diagrams in anaesthesia risk management include improved understanding of anaesthesia hazards and risks, pre-emptive identification of absent or inadequate hazard controls, investigation of clinical incidents, teaching anaesthesia risk management, and demonstrating risk management strategies to third parties when required.

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  • Focus on thrombin: alternative anticoagulants.

    Merry, Alan (2007-12)

    Journal article
    The University of Auckland Library

    Unfractionated heparin and protamine have been integral to cardiopulmonary bypass since cardiac surgery was first undertaken. These drugs are inexpensive and well understood but are contraindicated in some individuals, and resistance to heparin can be problematic in others. The interplay between the endothelium, anticoagulants, the coagulation cascade, and the inflammatory response that characterizes cardiac surgery may contribute to some of the complications associated with cardiopulmonary bypass. Various alternative drugs and strategies have been used to manage patients unsuitable for heparin or protamine, but each has its own disadvantages. At present, direct thrombin inhibitors may offer the best available alternative to heparin in cardiac surgery, particularly the short-acting bivalirudin, but this class of anticoagulants is relatively expensive and has no reversal agent. Balanced anticoagulation using combinations of drugs that act at different stages in the coagulation system may improve the management of coagulation in cardiac surgery, but careful investigation of this concept is needed.

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  • Can team training make surgery safer? Lessons for national implementation of a simulation-based programme

    Weller, Jennifer; Civil, Ian; Torrie, Jocelyn; Cumin, David; Garden, A; Corter, A; Merry, Alan (2016-10-14)

    Journal article
    The University of Auckland Library

    AIM: Unintended patient harm is a major contributor to poor outcomes for surgical patients and often reflects failures in teamwork. To address this we developed a Multidisciplinary Operating Room Simulation (MORSim) intervention to improve teamwork in the operating room (OR) and piloted it with 20 OR teams in two of the 20 District Health Boards in New Zealand prior to national implementation. In this study, we describe the experience of those exposed to the intervention, challenges to implementing changes in clinical practice and suggestions for successful implementation of the programme at a regional or national level. METHODS: We undertook semi-structured interviews of a stratified random sample of MORSim participants 3-6 months after they attended the course. We explored their experiences of changes in clinical practice following MORSim. Interviews were recorded, transcribed and analysed using a general inductive approach to develop themes into which interview data were coded. Interviews continued to the point of thematic saturation. RESULTS: Interviewees described adopting into practice many of the elements of the MORSim intervention and reported positive experiences of change in communication, culture and collaboration. They described sharing MORSim concepts with colleagues and using them in teaching and orientation of new staff. Reported barriers to uptake included uninterested colleagues, limited team orientation, communication hierarchies, insufficient numbers of staff exposed to MORSim and failure to prioritise time for team information sharing such as pre-case briefings. CONCLUSION: MORSim appears to have had lasting effects on reported attitudes and behaviours in clinical practice consistent with more effective teamwork and communication. This study adds to the accumulating body of evidence on the value of simulation-based team training and offers suggestions for implementing widespread, regular team training for OR teams.

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  • Paperless anesthesia: uses and abuses of these data

    Anderson, Brian; Merry, Alan (2015-12)

    Journal article
    The University of Auckland Library

    Demonstrably accurate records facilitate clinical decision making, improve patient safety, provide better defense against frivolous lawsuits, and enable better medical policy decisions. Anesthesia Information Management Systems (AIMS) have the potential to improve on the accuracy and reliability of handwritten records. Interfaces with electronic recording systems within the hospital or wider community allow correlation of anesthesia relevant data with biochemistry laboratory results, billing sections, radiological units, pharmacy, earlier patient records, and other systems. Electronic storage of large and accurate datasets has lent itself to quality assurance, enhancement of patient safety, research, cost containment, scheduling, anesthesia training initiatives, and has even stimulated organizational change. The time for record making may be increased by AIMS, but in some cases has been reduced. The question of impact on vigilance is not entirely settled, but substantial negative effects seem to be unlikely. The usefulness of these large databases depends on the accuracy of data and they may be incorrect or incomplete. Consequent biases are threats to the validity of research results. Data mining of biomedical databases makes it easier for individuals with political, social, or economic agendas to generate misleading research findings for the purpose of manipulating public opinion and swaying policymakers. There remains a fear that accessibility of data may have undesirable regulatory or legal consequences. Increasing regulation of treatment options during the perioperative period through regulated policies could reduce autonomy for clinicians. These fears are as yet unsubstantiated.

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  • In Reply

    Gargiulo, Derryn; Mitchell, Simon; Sheridan, Jane; Short, TG; Swift, Simon; Torrie, Jocelyn; Webster, Craig; Merry, Alan (2016-10)

    Journal article
    The University of Auckland Library

    We thank Tafelski et al. for making some interesting points about our recent study1 and asking for clarification of some issues. We agree that for various reasons, our results may be an underestimate, and we discussed these in some length in our article. With respect to the Hawthorne effect, we agree that our findings may reflect an underestimation of the actual rate of syringe contamination. Indeed, in the article, we indicated that ???anesthesiologists were encouraged to behave ???normally??? in respect of their aseptic practice,??? but that ???the open-label nature of the study may have influenced them to be more fastidious.???

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  • Improved compliance with the World Health Organization Surgical Safety Checklist is associated with reduced surgical specimen labelling errors

    Martis, WR; Sturge, Jacqueline; Lee, T; Merry, Alan; Mitchell, Simon (2016-09-09)

    Journal article
    The University of Auckland Library

    AIMS: A new approach to administering the surgical safety checklist (SSC) at our institution using wall-mounted charts for each SSC domain coupled with migrated leadership among operating room (OR) sub-teams, led to improved compliance with the Sign Out domain. Since surgical specimens are reviewed at Sign Out, we aimed to quantify any related change in surgical specimen labelling errors. METHODS: Prospectively maintained error logs for surgical specimens sent to pathology were examined for the six months before and after introduction of the new SSC administration paradigm. We recorded errors made in the labelling or completion of the specimen pot and on the specimen laboratory request form. Total error rates were calculated from the number of errors divided by total number of specimens. Rates from the two periods were compared using a chi square test. RESULTS: There were 19 errors in 4,760 specimens (rate 3.99/1,000) and eight errors in 5,065 specimens (rate 1.58/1,000) before and after the change in SSC administration paradigm (P=0.0225). CONCLUSIONS: Improved compliance with administering the Sign Out domain of the SSC can reduce surgical specimen errors. This finding provides further evidence that OR teams should optimise compliance with the SSC.

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