Table 2 The action list tool with six successfully implemented tasks

1.

2020, January

Haemorrhage (blood loss > 500ml) after deep excision

Insufficient knowledge about hemostasis material in colposcopy room.

Inventory of (available) options for haemostatic material (websearch) after a leep excision.

Liquid silver nitrate and Surgicel© as standard absorbable hemostats in the colposcopy room.

All team members are aware of which materials are present and where its stored in the colposcopy room.

Lecture held on absorbable hemostats.

Liquid silver nitrate is no longer available.

2.

2020, February

Recurrent urinary tract infection due to urinary retentions after removing the bladder catheter too soon following a Wertheim-Meigs procedure.

Make bladder scans required after Wertheim-Meigs procedure when catheter is removed as urine retention occurs more often. If necessary, long term catheter à demeure, self-catherization are options.

Standard of care protocol used at the ward which bladder retentions are acceptable after a specific procedure

Healthcare professional assigned to the action will check and modify the protocol if necessary.

There is a standard protocol at the inpatient department after surgical procedures of urology, surgery and gynaecology. Protocol does not need to be modified.

Additional action:

Everyone is aware of this hospital wide protocol.

3.

2020a, June

Wound dehiscence (“space belly”).

The suture used for closing the fascia was too short. Two sutures were tied together, leading to a weak spot.

Based on new advice - long polydioxanone suture (PDS) barrel (300 cm) is ordered.

Order long PDS barrel.

The PDS barrel is ordered and since July 2020 both short PDS barrel (120 cm) and long barrel (300 cm) are available.

4.

2020, July

Excessive CO2 accumulation during a laparoscopic procedure.

Clear communication during surgery about peri-operative issues between anesthesiology team and operative team.

In patients with higher BMI, the use of longer trocars is necessary to prevent CO2 leakage subperitoneal.

If necessary, introduce additional time-out during OR in case of impending complications.

Order longer trocars.

Repeat the outcome at the following M&M meeting.

Order longer trocars.

Create awareness of the risk of CO2 accumulation during surgery.

Actions are accomplished, and discussed again at the following meeting.

5.

2020, August

Overbalanced liquid intake postoperatively.

The liquid balance was not documented.

During each bedside rounds the liquid balance is documented (input and output within a 24-hour period in millimeters).

Organize education on liquid balance for registrars and nurses and at the inpatient ward.

State liquid balance in the electronic patient file at every bedside round.

Additional education for registrars and nurses on the overbalanced liquid intake policy postoperatively took place.

6.

2020, September

Wound infection.

High risk of infection after inguinal wound. Particularly in patients with obesity.

Research of other products that may aid in wound repair.

Start flushing the wound postoperatively with povidone iodine solution.

Communicate with infection prevention/ hospital hygienist to determine how to reduce the risk of wound infection with these procedures.

-> Evaluate the outcome of the use of povidone iodine solution at the end of surgery in relation to wound infections

Each staff member will record in the OR report whether the wound was flushed postoperatively for 6 months.

Schedule appointment with hospital hygienist.

Each staff member is aware that whether or not the wound was flushed with povidone iodine solution needs to be stated in the patient’s operating report.

Contact has been made with hospital hygienist at a later stage

(Due to COVID-19 this was postponed).

After 6 months the use of povidone iodine solution was evaluated (data from operating reports).