The role of documents and documentation in communication failure across the perioperative pathway. A literature review

International Journal of Nursing Studies 48 (2011) 1024–1038

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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns

Review

The role of documents and documentation in communication failure across the perioperative pathway. A literature review Sandra Braaf *, Elizabeth Manias, Robin Riley Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 5 November 2010 Received in revised form 18 May 2011 Accepted 19 May 2011

Objective: Communication practices of healthcare professionals have been strongly implicated in the cascade of events that unfold into poor outcomes for surgical patients. The purpose of this paper is to explore the role of documents and documentation in communication failure among healthcare professionals across the perioperative pathway. The perioperative pathway consists of 3 interconnecting, but geographically distinct domains: preoperative, intraoperative and postoperative. Design: A comprehensive search of the literature was undertaken to provide a focused analysis and appraisal of past research. Data sources: Electronic databases searched included the Cochrane Database of Systematic Reviews, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline and PsycINFO from 1990 to end February 2011. Additionally, references of retrieved articles were manually examined for papers not revealed via electronic searches. Review methods: Content analysis was used to draw out major themes and summarise the information. Results: Fifty-nine papers were selected based on their relevance to the topic. The results highlight that documentation such as surgeons’ operation notes, anaesthetists’ records and nurses’ perioperative notes, deficient in the areas of design, quality, accuracy and function, contributed to the development of communication failure among healthcare professionals across the perioperative pathway. The consequences of communication failure attributable to documentation ranged from inefficiency, delays and increased workload, through to serious adverse patient events such as wrong site surgery. Documents that involve the coordination of verbal communication of multidisciplinary surgical teams, such as preoperative checklists, also influenced communication and surgical patient outcomes. Conclusions: Effective communication among healthcare professionals is vital to the delivery of safe patient care. Multiple documents utilised across the perioperative pathway have a critical role in the communication of information essential to the immediate and ongoing care of surgical patients. Failure in the communicative function of documents and documentation impedes the transfer of information and contributes to the cascade of events that results in compromised patient safety and potentially adverse patient outcomes. Crown Copyright ß 2011 Published by Elsevier Ltd. All rights reserved.

Keywords: Communication Document Documentation Literature review Perioperative Record keeping

What is already known about the topic?

* Corresponding author. E-mail addresses: [email protected], [email protected] (S. Braaf).

 Poor documentation contributes to sentinel and adverse hospital inpatient events locally and internationally.  Flawed communication is a highly preventable contributor to sentinel and adverse hospital inpatient events.

0020-7489/$ – see front matter . Crown Copyright ß 2011 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2011.05.009

S. Braaf et al. / International Journal of Nursing Studies 48 (2011) 1024–1038

 The perioperative setting is a complex area vulnerable to sentinel and adverse patient events. What this paper adds  This review highlights the importance of addressing the communicative quality and function of documents and documentation from a multidisciplinary perspective across the perioperative pathway.  Documentation performed by healthcare professionals in the perioperative environment, such as surgeons’ operation notes, anaesthetists’ records and nurses’ perioperative notes, has the potential to result in communication failure and the delivery of suboptimal patient care.  Documents such as preoperative checklists have the capacity to be used in coordinating verbal communication of multidisciplinary surgical team members within the perioperative environment, thereby improving patient care. 1. Introduction and background Communication practices of healthcare professionals have been strongly implicated in the cascade of events that unfold into poor outcomes for surgical patients. Locally and internationally, research into sentinel and adverse events, consistently demonstrates the operating room environment and communication breakdown as recurring constituents in the generation of serious adverse incidences (Australian Institute of Health and Welfare (AIHW) and Australian Commission on Safety and Quality in Health Care (ACSQHC), 2008; Joint Commission on Accreditation for Healthcare Organizations (JCAHO), 2007; National Patient Safety Agency (NPSA), 2009). Additionally, flawed communication is routinely identified as a highly preventable contributor to adverse inpatient events (JCAHO, 2007), making investigation into healthcare professionals’ communication in the perioperative environment an area worthy of attention. Communication failure, defined as a flaw in the content, audience, occasion or purpose of the communication act (Lingard et al., 2006), can transpire from all forms of communication including documents and documentation. A document is written, printed or electronic text that provides a record of information that is typically used by healthcare professionals as a resource, such as hospital protocols, policies or guidelines. By comparison, documentation involves the accumulation and dissemination of information, such as the process of recording patient data on an anaesthetic chart or in a patient’s medical record (Moore, 2004). Australian and US sentinel event reports reveal that documents and documentation are significant factors in the development of events that lead to serious patient harm (AIHW and ACSQHC, 2008; JCAHO, 2007). Australian sentinel event reports for 2007–2008, identify written and verbal communication as contributing factors to 16% of all sentinel events, whereas policy and procedure guideline documents are noted to play a part in 43% of all sentinel events (AIHW and ACSQHC, 2008). In the US, root cause analysis of all sentinel events found communication

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(verbal and written) to be the main cause (JCAHO, 2007). Notably, these findings highlight documents and documentation as problematic, and a cause of failure in healthcare professionals’ communication. Providing leadership on global health matters, the World Health Organisation (WHO) guidelines for safe surgery recognises the vital role of documents and documentation for effective communication and the exchange of critical information in the operating room (WHO, 2009). The WHO acknowledges that clear, accurate and available documents and documentation are paramount to preserving patient safety. However the patient’s surgical journey expands beyond the isolation of the operating room, as the patient travels through 3 interconnecting, but geographically distinct domains: preoperative, intraoperative and postoperative, collectively known as the perioperative pathway (Australian College of Operating Room Nurses (ACORN), 2006). Multidisciplinary surgical teams utilise documentation from a variety of sources over the course of the perioperative pathway. Nurses customarily receive the patient for surgery into a preoperative holding area and screen the documentation prepared in the unit from where the patient has originated. As the patient progresses to the operating room, the documentation disperses as nurses, anaesthetists and surgeons all take responsibility for recording different information. Gradually, the documentation reunites in the post anaesthetic care unit (PACU), in preparation for the patient’s details to be passed on to a postoperative unit. Thus, as the patient transits through multiple departments, healthcare disciplines and clinical teams of the perioperative pathway, the critical role of documentation in relaying information is highlighted, particularly in the context of clinical handover. Documentation of patient data can be used to supplement verbal methods of communication and increase the reliability of information when healthcare professionals handover (Bhabra et al., 2007; Pothier et al., 2005). Clinicians working across the perioperative pathway also draw on documents for the purposes of coordinating work, which in turn are used to organise verbal communication. Hospital protocols, for example, which stipulate the preparation and transfer of patients to the operating room, organise clinicians’ time and work space to coordinate and shape their work activities (Riley and Manias, 2007). Hence, communication of accurate and current information in these documents is paramount for the delivery of quality and safe patient care. 2. Methods 2.1. Research questions and purpose The research questions framing this paper are: what is the role of documents and documentation in developing communication failure among healthcare professionals across the perioperative pathway? What are the possible effects on patients from communication failure among healthcare professionals across the perioperative pathway? The purpose of this paper is to explore the role of documents and documentation in communication failure

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S. Braaf et al. / International Journal of Nursing Studies 48 (2011) 1024–1038

among healthcare professionals across the perioperative pathway and consequently this paper’s strengths lie in multiple areas. In distinction to other reviews on documents and documentation this paper takes a multidisciplinary approach, incorporating papers from across the perioperative pathway and not just from an isolated domain. Further, this paper focuses on multiple communicative functions of documents and documentation, including the many consequences that may occur when these functions breakdown. 2.2. Data sources The inclusion criteria for this review incorporated: (1) original studies published from 1990 to end February 2011; (2) papers printed in the English language; (3) papers that contain content directly addressing documents or documentation (written, printed or electronic) used by healthcare professionals for communication in clinical practice and (4) papers relating to the intraoperative period or immediate preoperative and postoperative periods. Papers were excluded if the main focus of the paper was not on a document or documentation that would be utilised by healthcare professionals for

Search of key terms documentation or medical audit or medical records systems, computerized or safety management or medical records and anesthestia or anesthesiology

communication in clinical practice, the paper was not relevant to the perioperative pathway and/or the quality audit had not been published. Databases searched included the Cochrane Database of Systematic Reviews, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline and PsycINFO from 1990 to end February 2011. As the aim of the search was to generate papers from various disciplines, including nursing, surgery and anaesthetics, the search strategy was separated into components (Fig. 1). To retrieve relevant research, electronic databases were searched using a combination of the key terms, namely: documentation, medical audit, medical records systems computerised, safety management, medical records, nursing records, anesthestia, anesthesiology, surgical procedures operative, general surgery, communication, and perioperative, perioperative nursing, intraoperative care and postoperative care. The search generated 1669 articles, and through a selection process, 1562 were rejected after reading the title and/or abstract of the article. The search yielded 3 systematic reviews relating to record keeping; however, they were not specific to the perioperative area and were confined to the nursing profession and therefore excluded.

Search of key terms documentation or medical audit or medical records systems, computerized or safety management or medical records and surgical procedures, operative or general surgery and communication

1669 papers from electronic databases 19902011

Search of key terms documentation or nursing records and perioperative or perioperative nursing or intraoperative care or postoperative care

1562 papers excluded based on evaluation of title and / or abstract

107 papers retrieved for further evaluation Papers excluded for not meeting inclusion criteria 29 papers selected based on inclusion criteria 4 papers duplicated 34 papers from manual examination of references of retrieved papers

25 papers based on inclusion criteria

Total of 59 papers included in structured literature review Fig. 1. Flowchart illustrating the selection of papers for literature review.

75%d Intraoperative Anaesthesia record Survey study

Randomised retrospective audit

Retrospective review of records

Prospective audit

Intraoperative Surgeon’s operation notes Intraoperative Surgeon’s operation reports Intraoperative Surgeon’s operation notes

264 general surgical operation notes from 2 district general hospitals 50 handwritten and 30 electronic operation reports for unilateral hip arthroplasty reviewed 100 notes selected from list of patients who had surgery in a single otorhinolaryngology department Convenient sample of 4989 anaesthesia records evaluated from 4 academic centres and 5 community hospitals

10 of the 13 identified indicators were omitted on just less than 6% of records

50%a

64%a

60%a

57%a

Following proforma introduction there was a statistically significant increase (p = 0.001) in the documentation Postoperative instructions were omitted in nearly 2/3 of the operation notes. Adherence to RCS guidelines significantly improved with electronic proforma (p < 0.01) Aide-memoire improved the quality of operation notes with respect to the measured criteria 88 case notes from 2 hospitals assessed Intraoperative Surgeon’s operation notes Randomised retrospective review of records

Findings and outcomes Sample and data collection Site and type of documents and documentation Research design

Biddle et al. (2001) US

Bateman et al. (1999) UK

Barritt et al. (2010) UK

Baigrie et al. (1994) UK

Examine a proforma for improving standard of operation notes in orthopaedic and trauma surgery Assess quality of surgeon operation notes at 2 district hospitals Assess extent of adherence to RCS* guidelines in handwritten and electronic notes How operation notes conform with RCS guidelines and avoided use of unacceptable abbreviations Identify 13 noteworthy charting components and examine anaesthesia records for rate of compliance

The findings from the papers generated 5 major themes: design of documentation; quality of documentation; accuracy in documentation of clinicians’ work activities; functions of documentation; and documents that coordinate verbal communication.

Al Hussainy et al. (2004) UK

3. Results

Research question/aim

Two independent reviewers undertook content analysis after initially appraising the selected papers for relevance and familiarisation. Once an impression of the data was obtained, recurrent words, concepts and phrases were noted to identify broad potential categories. Next, the dataset was revised and searched for patterns and connections by comparing and contrasting possible themes. Reoccurring categories were then recorded and clustered into major themes that formed the headings under which the data were summarised (Ritchie and Lewis, 2003; Sandelowiski, 2000).

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Reference and country of research

2.3. Review methods

Table 1 Studies investigating documents and documentation in communication failure among healthcare professionals across the perioperative pathway, 1990–2011.

The remaining 107 published papers were retrieved for further examination, of which 25 papers were relevant to the inclusion criteria. To expand the search, references of retrieved articles were manually examined for papers not revealed via electronic searches. Fifty-nine papers were selected for inclusion based on their relevance to the topic (Table 1). Included papers represented research conducted in 17 countries, predominantly within the years 2003– 2010. Of the selected papers a variety of research designs were reported, including prospective and retrospective audits and reviews of records, survey studies, observational studies, descriptive qualitative studies, as well as, pre and post intervention studies. Two independent reviewers evaluated all of the included papers for quality. The quality of survey studies was assessed using all items on the reporting checklist for evaluation of survey research as advised by Kelley et al. (2003). Accurate and complete reporting of observational studies was calculated using all items from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist (von Elm et al., 2007). An evaluation of good conduct and reporting of pre and post intervention studies was accomplished using the Transparent Reporting of Evaluations with Non-randomised Designs (TREND) statement (Des Jarlais et al., 2004). Descriptive qualitative studies were evaluated using guidelines for qualitative inquiry as proposed by Malterud (2001). Finally, audits and reviews of records were assessed using the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines (Davidoff et al., 2008). To generate a score for each paper, the quality tool for evaluation applicable to the papers’ research design was assigned one point to each relevant item, to calculate a total possible score. The score for each paper was then divided by the total possible score and multiplied by 100 to generate a percentage score. This percentage score is reported under the title ‘Quality evaluation’ in Table 1. In the event a study incorporated a combination of research designs, the paper was then evaluated using multiple tools.

Quality evaluation % score from validated tools

S. Braaf et al. / International Journal of Nursing Studies 48 (2011) 1024–1038

Research question/aim

Research design

Site and type of documents and documentation

Sample and data collection

Findings and outcomes

Quality evaluation % score from validated tools

Burda et al. (2005) US

Examine extent of medication and allergy discrepancies between surgical and anaesthesia preoperative medication histories Determine influences on counting errors and documentation errors in counting Assess completeness of documentation in web-based synoptic operative reporting system (WebSMR) compared to dictated operative reports Identify factors contributing to wrong-site surgery

Prospective observational cohort study

Preoperative Surgical and anaesthesia preoperative medication histories Intraoperative Nursing perioperative documentation Intraoperative Surgeon’s operation reports, electronic and written

Reviewed 79 preoperative medication histories of patients admitted postoperatively in 2 surgical ICU’s in 1 centre over 1 month 52 forms on errors in counting completed by nurses in 4 metropolitan and 2 private hospitals 271 randomly selected surgeon dictated operative reports were compared with 133 consecutive WebSMR documents

73% of records contained at least 1 discrepancy

90%b

Documentation errors in surgical counts are common. Multiple factors influence counting errors

71%d

63%a

427 reports of wrong site surgery in an operative venue reported to the Pennsylvania patient reporting system reviewed

Ascertain if electronic templates more efficient, and reduced errors, than dictated notes Ascertain medication-error potential associated with surgeon preference cards at a single healthcare institution

Retrospective review of records

Pre and intraoperative Consents Operative list Patient records Surgeon’s office records Intraoperative Surgeon’s operation notes

Improved quality of documentation from reduced omission of required information following introduction of the WebSMR Sources of documentation error were consent forms (12 reports), operating room schedules (111 reports), surgeons’ records (11 reports) and diagnostic test results (31 reports)

67%a

Retrospective review and clinical analysis

Intraoperative Surgeon’s operative preference cards

392 preference cards analysed. Review of information on cards and failure mode and effects analysis

Evaluate consistency between care given to patients and that documented in patients undergoing major abdominal surgery Evaluate 4 indicators of safety culture in perioperative setting following implementation of preoperative safety briefing

Observational study and review of records

Pre and postoperative Nursing records

Structured non-participant observation on 16 nurses. Retrospective audit of nursing records at a single hospital

Electronic operative notes had fewer errors and were quicker to complete compared to dictated notes Medications on the cards were outdated, contained wrong or missing information, or card layout made the medications difficult to find Nurses carry out more activities than they document as only 40% of nursing activities observed were documented in nursing records

Survey and retrospective review

Intraoperative Preoperative safety checklist

60 surgeons and 59 operating suite staff surveyed with safety attitudes questionnaire at a single healthcare institution. Retrospective review of risk data

Din et al. (2001) UK

Assess quality of operation notes in an orthopaedic department

Prospective audit

Intraoperative Surgeon’s operation notes

70 operation notes assessed, then 82 notes evaluated after aidememoire introduced

Driscoll et al. (2007) US

Review electronic anaesthesia records for 6 documentation elements

Retrospective chart review

Intraoperative Anaesthetic records

2838 records from AIMS database reviewed at a single healthcare facility

Butler et al. (2003) Australia

Chambers et al. (2009) Canada

Clarke et al. (2007) US

Cowan et al. (2007) US

Dawson et al. (2005) US

De Marinis et al. (2010) Italy

DeFontes and Surbida (2004) US

Survey study

Retrospective review of records

Retrospective review of records

58 dictation notes and 52 electronic template notes were reviewed

Wrong site surgery reduced 300%, employee satisfaction up 19%, nursing personnel turnover reduced 16% and perceptions of safety climate improved from ‘‘good’’ to ‘‘outstanding’’ Recording of patient details, operative steps and postoperative orders improved after aide– memoire Electronic clinical anaesthesia documentation was often incomplete

70%a

60%a

84%a 76%b

65%a 76%d

57%a

80%a

S. Braaf et al. / International Journal of Nursing Studies 48 (2011) 1024–1038

Reference and country of research

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Table 1 (Continued )

Edhemovic et al. (2004) Canada

The narrative report contained 45.9% of the specified data elements and WebSMR captured 99% Electronic records required less time to complete and produced a higher quality record

69%a

100 patient clinical notes randomly selected in an ophthalmic hospital

44 transposition errors in 32 sets of patients’ notes. 3 consent forms had incorrect eye noted

76%a

325 surveys distributed to practicing anaesthetist 75% response rate

Reported incidence of data omission or falsification was 55%

81%d

Perioperative Anaesthetic preoperative form Intraoperative Surgeon’s operation reports

5 days observing use of preoperative risk assessment forms and open-ended interviews 119 standard and 102 non standard cholecystectomy reports analysed

62%b

International prospective study using a pre/post intervention design

Intraoperative 19 item preoperative surgical safety checklist

7688 (3733 preintervention and 3955 postintervention) consecutively enrolled patients 16 years or older undergoing noncardiac surgery at 8 hospitals in 8 cities

Retrospective audit

Intraoperative Surgeon’s operation notes Intraoperative Perioperative nursing documentation Preoperative Medical records and charts

185 randomly selected operative notes assessed according to Ireland RCS guidelines 80% response rate. Questionnaire sent to the head nurse in each surgical department state-wide (n = 171) 197 reports of inadequate preoperative patient preparation and/or evaluation analysed

Use of risk assessment form by anaesthetists can be at variance with organisational use Standard operative reports resulted in more complete and reliable operative data than non standard reports The death rate of 1.5% prior to checklist introduction declined to 0.8% afterward (p = 0.003). Inpatient complication rate reduced from 11% pre checklist introduction to 7% after its introduction (p < 0.001) 86.5% of operation reports documented by trainee surgeons

Retrospective review of records

Intraoperative Surgeon’s operation notes

198 dictation reports and 138 template reports evaluated for 5 obstetric and gynaecological procedures at 1 hospital

Retrospective audit

Intraoperative Surgeon’s operation notes Intraoperative Anaesthetic chart

190 operation notes audited in 1 hospital in a surgical department

Randomised retrospective review

Intraoperative Surgeon’s operation report

40 random standard narrative operation reports from 7 hospitals compared with 40 WebSMRs

Case study and record review

Intraoperative Anaesthetic records

10 consecutive patients undergoing knee arthroscopies under general anaesthetic

Retrospective review of records

Assess if anaesthetist knowingly omitted or modified physiological anaesthetic chart records Describe and understand practical aspects of document use by anaesthetists Compare completeness and reproducibility of data in standard and non standard operative report Test hypothesis that implementation of surgical safety checklist and associated cultural change it signified would reduced rate of death and major complications after surgery Evaluate quality of written operative notes for surgical patients in a teaching hospital Explore current practices and contents of nursing perioperative documentation

Survey study

Admission to discharge Operation notes Consent forms Intraoperative Anaesthetic records

Kluger et al. (2000) Australia

Identify problems with preoperative patient evaluation and preparation and to suggest remedial strategies

Retrospective review of anaesthetic incident monitoring database

Laflamme et al. (2005) US

Compare timeliness and comprehensiveness of operative notes in electronic templates versus dictation services To audit surgical notes against a quality criteria Analyse the accuracy of computer system records and anaesthetic chart

Retrospective, prospective review

Edsall et al. (1993) US

ElGhrably and Fraser (2008) UK

Galletly et al. (1991) New Zealand

Harper et al. (1997) UK

Harvey et al. (2007) Canada

Haynes et al. (2009) Canada, New Zealand, India, UK, Philippines, Tanzania, Jordan, US

Jawaid et al. (2008) Pakistan Junttila et al. (2000) Finland

Lefter et al. (2008) Australia Lillywhite and Ward (1993) UK

Observational study

Retrospective review of reports

Survey study

Reviewed 427 operations and 215 anaesthetic charts

73%a

63%a

88%c

63%a

62% of respondents identified documentation as repetitive. If no perioperative form, information recorded on anaesthetic record Communication problems 2nd most common contributing factor to incidents (23%). Deficiencies in written notes most common cause of communication breakdown Templates resulted in faster times to the presence of a verified operative report in the medical record, compared to dictation services (p < 0.001) 51% of operation notes were incomplete

81%d

40% of anaesthetic charts missing. 33-52% accuracy in computerised audit system

52%a

72%a

S. Braaf et al. / International Journal of Nursing Studies 48 (2011) 1024–1038

Assess degree of congruency between WebSMR and standard narrative report in rectal cancer surgery Compare manual and electronic anaesthesia systems with regards to quality and time demands Assess how often left/right transposition errors occurred in patients clinical notes

67%a

69%a

1029

Research question/aim

Research design

Site and type of documents and documentation

Sample and data collection

Findings and outcomes

Quality evaluation % score from validated tools

Lingard et al. (2008) Canada

Assess whether structured team briefings improve operating room communication in an academic tertiary care hospital

Prospective study using a pre/post intervention design

Intraoperative Preoperative checklist

Checklist briefing reduced number of communication failures per procedure from 3.95 preintervention to 1.31 postintervention (p < 0.001)

85%c

Marco et al. (2003) US

Determine impact of changes in form design on the capture of administrative and clinical data elements Extent of surgeon adherence to RCS guidelines on recording operative notes Describe quality of postoperative documentation to identify patient and hospital factors associated with incomplete documentation Survey airway assessment, its documentation, availability of equipment and difficult airway plans Audit the quality of operative notes for total knee replacements against standards set by the British Orthopaedic Association Audit quality of caesarean section documentation and its adherence to guidelines Determine quality of operation notes in manual and computerised form for patients undergoing surgery for colorectal cancer at single institution Assess reliability and completeness of electronic synoptic operative reports

Randomised retrospective chart review

Preoperative Preoperative anaesthetic form

86 preintervention and 86 postintervention procedures observed. 11 general surgeons, 24 surgical trainees, 41 operating room nurses, 28 anaesthetists, and 24 anaesthesia trainees 112 old charts and 105 new charts were reviewed at a single academic health centre

77%a

Retrospective review of records

Intraoperative Surgeon’s operation notes Postoperative Patient medical records

52 patients undergoing surgery at a district general hospital were randomly selected The medical records of 211 adult patients following major surgery in 5 Australian hospitals were audited

Survey study

Preoperative Preoperative anaesthetic records

Clinical directors of 69 anaesthesia departments were surveyed. 81% response rate

Prospective audit

Intraoperative Surgeon’s operation notes

70 operation notes of surgical patients a district hospital audited. Following surgeon education and checklist, 49 notes re-audited

Randomised retrospective audit

Intraoperative Surgeon’s operation notes Intraoperative Surgeon’s operation notes

137 case notes sampled in a university hospital. Following proforma 137 notes re-audited Reviewed 100 written and 100 computerised notes. A further 100 written and 100 computerised notes prospectively collected

Proposed surgery and American Society of Anaesthesiologists physical status documented with a lower frequency on new form Postoperative instructions were recorded in 71% of consultant’s notes and 90% of registrars During the first 3 postoperative ward days only 17% of medical records had complete documentation of vital signs and medical and nursing reviews Preoperative airway evaluation is performed in 90% of departments, yet the results of the tests were documented in only 38% There was a significant increase in the mean number of data points recorded per note from 9.6 to 13.1 (p < 0.0001) following surgeon education and checklist Multiple omissions in operative delivery notes. Operative proforma led to improved documentation Computer notes scored higher on all criteria measuring the quality of operation notes

Prospective review of records

Intraoperative Surgeon’s operative notes

112 electronic synoptic operative reports for major pancreatic resections reviewed

Patel (1993) UK

Assess extent to which hospital records follow the guidelines published by RCS

Retrospective review of records

200 consecutive discharges were reviewed at 2 surgical units at 2 hospitals

Powsner et al. (2000) US

Compare clinicians comprehension with pathologists intent in written pathology reports

Survey study

Intraoperative Surgeon’s operative notes Consent forms Postoperative Pathology reports

Mathew et al. (2003) UK McGain et al. (2008) Australia

Mellado et al. (2004) Denmark

Morgan et al. (2009) UK

Nicopoullos et al. (2003) UK O’Bichere and Sellu (1997) UK

Park et al. (2010) US

Retrospective audit of records

Retrospective and prospective evaluation

34 general surgical attending physicians and trainees reviewed 6 anatomical pathology reports followed by questionnaire

67%a

84%a

81%d

66%a

65%a

53%a

Electronic synoptic operative reports more complete than dictated reports (p < 0.001) and available faster (p < 0.01) Inadequacies were predominantly due to the use of abbreviations

76%a

Comprehension of reports were not consistent with pathologists’ intention, as surgeons misunderstood pathologists’ reports for 30% of the time

70%d

75%a

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Reference and country of research

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Table 1 (Continued )

Pre, intra and postoperative Operating theatre lists Pre and intraoperative Surgeon and anaesthetic records Postoperative Postoperative nursing records

281 theatre lists compared to originally submitted list to identify errors and alterations

78% of theatre lists contained errors or omissions and 45% were altered in theatre

45%a

104 operative and 101 anaesthetic records reviewed on all patients over 1 month

59%a

Intraoperative Surgeon’s operation notes Intraoperative Surgeon’s operation notes

100 operation notes audited for compliance with RCS guidelines

Areas lacking documentation were details of patient position, patient airway, results of investigations and postoperative plans The respiratory and circulatory status of patients and their fluid balance were inadequately recorded 66% of operation notes completed by trainee surgeons

137 operation notes audited. 151 reaudited after aide memoire

Significant improvement in documentation of operation notes

74%a

Descriptive observational study

Pre and intraoperative Documents used pre and intraoperatively

Surgeons, resident, anaesthetists, nurses and case managers observed for 40 hours at 2 outpatient surgical facilities

60%b

Identify the causes of surgical error and opportunities for prevention Examine accuracy of manual anaesthetic records compared to observer records

Retrospective review of malpractice claims

Pre, intra and postoperative

Observational study and review of records

Intraoperative and postoperative Anaesthetic record

444 closed malpractice claims from 4 malpractice liability insurers were reviewed 197 records of patients undergoing general or major regional anaesthesia

Assess quality of operative notes and compare to England RCS guidelines Determine adequacy of consent documentation related to descriptions of intended procedures, associated risks and alternative treatments Analysis of preoperative anaesthetic records for 12 agreed core items of preoperative assessment Analyse malpractice claims to improve aetiology of surgical errors and determine avoidable causes Evaluate overall quality of preoperative anaesthesia evaluation forms in the US

Prospective audit

Intraoperative Surgeon’s operation notes Preoperative Consent and booking forms

Verification of surgical sites vulnerable to error by time pressures, complex work processes, communication culture, attention/distraction and documentation issues The second most common system factor contributing to error was communication breakdown (24%) Inaccuracies were found in text entries of manually compiled anaesthetic records compared with observation After aide-memoir, 100% recording of audited information

Measure incidence of errors, omissions and alterations in completed operating lists

Prospective audit

Roach et al. (1998) Hong Kong

Assess content and accuracy of operative and anaesthetic records for caesarean sections at 1 hospital Evaluate the record keeping of postoperative nursing care in a single hospital

Retrospective review of records

Assess the accuracy of operative notes in a general surgical unit Audit operation note compliance with RCS guidelines in a plastic surgery department Examine factors that promoted or hindered correct identification in surgical procedures

Retrospective audit

Roets et al. (2002) South Africa

Rogers et al. (2008) UK

Rogers and Pleat (2010) Canada

Rogers et al. (2004) US

Rogers et al. (2006) US

Rowe et al. (1992) New Zealand

Shayah et al. (2007) UK

Siddins et al. (2009) Australia

Simmonds and Petterson (2000) UK

Somville et al. (2010) Belgium

Takata et al. (2001) US

Retrospective audit

Retrospective audit

Retrospective review of consent forms

Retrospective and prospective audits

Preoperative Preoperative anaesthetic records

Retrospective review of surgical malpractice claims

Pre, intra and postoperative Medical and nursing records Preoperative Preoperative anaesthetic evaluation forms

Survey study

186 patient records retrospectively audited and evaluated against a checklist

100 operative notes audited. Reaudit following introduction of aide–memoir On 3 occasions consent forms for all patients on a urology unit waiting list at a repatriation general hospital reviewed. 1280 consent forms evaluated 195 patient notes audited. A formatted sheet was introduced and 227 records reaudited Review of 427 surgical malpractice claims forms at one malpractice insurance company 138 preoperative evaluation forms evaluated. 52.7% response rate

63%a

60%a

80%a

62%a 67%b

57%a

Procedure description provided on the consent form differed to the booking form in 55.7% of cases

81%a

No patient had 11 or 12 pieces of preoperative information recorded. Small but non-significant improvement in 2nd audit A leading system factor was communication breakdown (42% of cases)

87%a

Nearly 15% of institutions had substandard to severely deficient preoperative evaluation forms

87%d

S. Braaf et al. / International Journal of Nursing Studies 48 (2011) 1024–1038

Reed and Phillips (1994) UK

79%a

1031

1032

Table 1 (Continued ) Research question/aim

Research design

Site and type of documents and documentation

Sample and data collection

Findings and outcomes

Quality evaluation % score from validated tools

Tessler et al. (2006) Canada

Document opinions on variables important to document on anaesthetic charts

Survey and retrospective chart review

Preoperative and intraoperative Anaesthetic records

Staff anaesthetists at 4 hospital sites. 90% response rate. 60 patient records from the 4 sites randomly selected and evaluated

72%a 88%d

Trivedi et al. (2009) UK

Prescribing of antibiotics and analgesics by anaesthetists

Prospective audit

Wauben et al. (2010) Netherlands

Assess compliance with Dutch guidelines for writing operative notes Assess whether the implementation of a WHO surgical safety checklist in urgent surgical cases improves compliance with basic standards of care and reduce rates of death and complications Understand surgeon information transfer and communication that affects quality and efficiency of inpatient care

Retrospective audit

Intra and postoperative Drug and anaesthetic charts Intraoperative Surgeon’s operation notes Intraoperative Preoperative surgical checklist

100 consecutive drug charts were audited. Following dissemination of results and education, audit was repeated Analysed 171 operation reports (in 9 hospitals) on laparoscopic cholecystectomy Clinical process and outcome data for 1750 (842 preintervention and 908 postintervention) consecutively enrolled patients 16 years or older undergoing urgent non-cardiac surgery

Airway and allergy status considered most important preoperative variables to record yet 84% recorded patient’s allergy status and 49% documented airway 48% of paracetamol prescriptions, 25% of NSAID, and 62% of antibiotics recorded. Increased recording in 2nd audit Most notes complied with the Dutch guidelines (52-69%) The complication rate fell (p = 0.0001) and the death rate fell (p = 0.0067) after the checklist was introduced

85%c

Descriptive qualitative study

The hospital environment Patient records

3 focus groups of surgeons and nurses at 5 medical centres. Web survey and 328 case descriptions and general comments on incidents classified

80%e

Compare completeness of information contained in electronic versus handwritten records Assess the current state of report information quality of colorectal carcinomas

Retrospective audit

Intraoperative Anaesthetic records

70 handwritten records reviewed and after 8 months compared to 70 electronic records

Retrospective review of reports

Postoperative Pathology report

15940 reports from 532 laboratories were reviewed

Problems with written record were missing information, incorrect/out of date information, records not keeping up with patient, charts not read, buried/misplaced information No significant difference in completeness of electronic versus handwritten anaesthetic records (p = 0.16) Standardised report form or checklists increased likelihood of providing information on specimens

Weiser et al. (2010) Jordan, India, US, Tanzania, Philippines, Canada, UK, New Zealand

Williams et al. (2007) US

Wrightson (2010) New Zealand

Zarbo (1992) US Canada Australia

* a b c d e

Royal College of Surgeons. Davidoff et al. (2008). von Elm et al. (2007). Des Jarlais et al. (2004). Kelley et al. (2003). Malterud (2001).

Prospective pre and post intervention study

40%a

74%a

64%a

68%a

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Reference and country of research

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3.1. Design of documentation The layout and design of forms can impact on the documentation of information. Healthcare professionals may subsequently use this information to make important patient care decisions. A survey study conducted by Takata et al. (2001) investigated the quality of preoperative anaesthetist assessment forms from 138 US health institutions. A rating system based on perceived importance of information to anaesthesia management and legal regulation was used to score the forms. Fifteen percent of the forms reviewed were rated as severely deficient in informational content, lacking details such as exercise tolerance, surgical and anaesthetic history, and airway assessment. Twelve percent of forms were considered poor in relation to ease of use and 6% were poor in relation to ease of reading. Similarly, investigating documentation by anaesthetists, Marco et al. (2003) conducted a randomised, retrospective chart audit to evaluate the effect of a change in form structure on the recording of administrative and clinical information obtained during anaesthetic preoperative assessments. Changes to the form structure included the insertion of prompts for medical history, billing, compliance and medical assessment items. The information captured on 112 old forms was compared to 105 new forms and while the notes completed by attending anaesthetists were significantly improved, alterations to the form design actually deterred the recording of the proposed surgical procedure and the American Society of Anesthesiologists’ physical status classification. While both Takata et al.’s and Marco et al.’s investigations were restricted to documentation performed only by anaesthetists, the findings underscore the importance of form design in capturing patient data. However, neither study examined the relationship between deficient content in documentation and communication or adverse patient outcomes. 3.2. Quality of documentation Multiple studies from the disciplines of nursing, anaesthesia and surgery, have involved investigations into the quality of perioperative documentation. Key issues highlight concerns relating to operation notes, anaesthetic records, nurses’ perioperative notes, medication records, nurses surgical count records and documentation used to perform patient safety checks. In evaluating documentation quality, many audits involved appraisals of surgeons’ documentation against standards set by governing surgical professional bodies within the country of research. Common to the majority of audits was the finding of frequent omissions in surgeons’ documentation. Surgeons’ notes frequently omitted postoperative instructions (Baigrie et al., 1994; Lefter et al., 2008; Mathew et al., 2003), operative results and actions undertaken (Roach et al., 1998; Rogers et al., 2008; Shayah et al., 2007) and operative complications (Al Hussainy et al., 2004; Jawaid et al., 2008; Wauben et al., 2010). Additionally, surgeons’ notes were found to contain unacceptable abbreviations and illegible content (Baigrie

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et al., 1994; Din et al., 2001; Jawaid et al., 2008). While these audits generally revealed poor quality documentation, none of the researchers reported any subsequent effects on patient care or healthcare professionals’ communication. Findings from chart reviews and survey studies of anaesthetists’ pre and intraoperative records also revealed poor quality documentation. A Canadian survey and chart review study involved recording the opinions of anaesthetists at 4 hospitals on the variables they considered important to document (Tessler et al., 2006). The results from 240 surveys sent (with a 90% response rate), indicated that airway and allergy status were considered the most important preoperative variables to record. However, what was perceived as important to anaesthetists differed to what they practised, as only 84% recorded the patient’s allergy status and 49% documented airway evaluation. Similarly, Roach et al. (1998), Mellado et al. (2004), Simmonds and Petterson (2000) and Biddle et al. (2001), all found documentation of patient allergies and airway assessment to be lacking. None of the researchers, however, investigating anaesthetists’ pre and intraoperative records addressed any communication or patient care consequences from poor quality documentation. From a nursing perspective, a survey study conducted by Junttila et al. (2000), explored the current practices of nurses’ intraoperative documentation. A survey was sent to the head nurse of 171 Finnish public and private surgical departments of which 137 responded (80% response rate). The documentation form used in each surgical department was also requested. The results revealed that 58% of respondents completed perioperative documentation for every patient, with the main reason for non-documentation cited as type and size of the surgery. The majority of respondents (n = 85) also indicated that intraoperative documentation was repetitive of information already noted on the anaesthetic record, and 10 respondents indicated they had discontinued using an intraoperative nursing record, as the record was no longer needed, or documentation was considered time consuming or repetitive. When a specific intraoperative record was not used (n = 41), 85% of nurses stated information was subsequently documented on the anaesthetic chart. Of the perioperative documentation forms returned, 38 were specific perioperative documents and another 15 were not nursing specific (most were anaesthetic records). Content analysis of open-ended survey questions identified the non-specific perioperative records contained less accurate documentation than the specific perioperative records (Junttila et al., 2000). Further, a prospective observational cohort study conducted by Burda et al. (2005) investigated patient medication documentation. The results revealed anaesthetists and surgeons inconsistently recorded patient allergies, types of medications and the medication dose and frequency. Similar irregularities were noted in a prospective audit conducted by Trivedi et al. (2009). The results showed the practice of recording intraoperative drug administration onto the anaesthetic chart by anaesthetists, and not the ward prescription chart, posed a risk to patients as a safe time interval between drug doses was not stipulated on the ward prescription chart.

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Furthermore, a retrospective review and clinical analysis undertaken by Dawson et al. (2005) investigated intraoperative medications recorded on surgeon preference cards. Surgeons’ preference cards, maintained by nurses, contain documentation on individual surgeons’ preferred options for surgical procedures, such as equipment setup and orders for medications (irrigation solutions, topical solutions and dyes). Findings revealed that the preference cards were frequently outdated, incorrect, confusing and had missing information, posing significant potential for medication errors to occur (Dawson et al., 2005). Although the findings by Burda et al., Trivedi et al. and Dawson et al. had the potential to gravely affect communication and patient safety, none of these researchers evaluated for these consequences. Only a handful of studies addressing documentation actually involved investigation of the causes and consequences of documentation failing in its communicative purpose across the perioperative pathway. From a nursing perspective, a survey study undertaken by Butler et al. (2003) investigated factors causing error in the surgical count. The surgical count promotes patient safety as all items utilised in surgery are accounted for at the end of the procedure. Fifty-two forms containing information on counting errors were analysed from 6 institutions. The results of Butler et al.’s investigation showed documentation errors (n = 35) occurred most often, with lost items causing 17 of these errors. Patient consequences included exposure to avoidable X-rays and increased anaesthetic time, while the staff consequences related to reduced efficiency, increased workload and stress. Errors in documentation were attributed to inexperienced nursing staff, multitasking, shift changes of scrub nurses and lengthy cases (Butler et al., 2003). These consequences, however, were not investigated for effects beyond the intraoperative environment. Documentation failure has also been strongly implicated in the cascade of events that lead to wrong site surgery. Research conducted by Rogers et al. (2004) established the role of inaccurate documentation causing breakdown in preoperative identification of the surgical site. In a descriptive observational study, Rogers et al. found inaccurate documentation contributed to complications with preoperative surgical site verification. While Rogers et al. (2004) did not expand their research beyond examining factors that promoted or hindered correct surgical site identification, the authors suggested that patients were rendered vulnerable to surgical error by flawed documentation. In a retrospective review of records conducted by Clarke et al. (2007) 427 reports of wrong site surgery (including near-miss and actual wrong site surgery) were submitted to the Pennsylvanian Patient Safety Authority. Of these reports documentation in consent forms (12 reports), operating room schedules (111 reports), surgeons’ records (11 reports) and diagnostic test results (31 reports) were all identified as sources of error. However, healthcare professionals verifying the surgical site with accurate documentation were able to avert wrong site surgery (Clarke et al., 2007). Although a direct link between inaccurate documentation and wrong site surgery was not

assessed, clearly, the potential to deliver suboptimal care exists with possibly devastating outcomes for patients. In an retrospective investigation into Australian preoperative anaesthetic incidents, deficiencies in medical records and charts were cited as the most common reason for communication breakdown, contributing to 23% of incidents of inadequate preoperative patient preparation and/or evaluation (Kluger et al., 2000). Other investigators also identified healthcare professionals’ communication across the perioperative pathway as a significant contributor to adverse events, but did not distinguish between verbal and written communication causes (Rogers et al., 2006; Somville et al., 2010; Williams et al., 2007). The results from investigations into the quality of documentation across the perioperative pathway all highlight the frequent presence of omissions and inaccuracies in documentation from multiple sources. Omissions and inaccuracies in documentation constitute flaws in information content, presenting abundant opportunities for communication failure, and the potential for serious errors, although many of these studies did not directly examine for communication or patient consequences. 3.3. Accuracy in documentation of clinicians’ work activities Documentation needs to be comprehensive and provides an accurate reflection of what occurs in clinical practice. The accuracy of anaesthetic and nursing records was evaluated in 2 studies involving observation of clinicians’ activities and subsequent review of written records (De Marinis et al., 2010; Rowe et al., 1992). Rowe et al. revealed inaccuracies in anaesthetists’ recordings of perioperative events such as the delivered volumes of intravenous fluids, the concentration of local anaesthetics (lignocaine and bupivacaine) and the site and timing of tourniquet application. De Marinis et al. showed the consistency between performed and recorded care declined on days when nurses were busier (first and second postoperative days), suggesting that these records were inadequate for the evaluation of nursing care actually delivered. While neither De Marinis et al. or Rowe et al. examined patient consequences, Rowe et al. (1992) speculated that patient safety may be compromised through planning future anaesthetic episodes with documentation that was not an accurate or complete record of events. Thus, failure to communicate an accurate summary of work activities through documentation has considerable potential to compromise patient safety (Kluger et al., 2000; Roach et al., 1998; Rowe et al., 1992). 3.4. Functions of documentation Documentation serves an assortment of functions such as recording information for audit, research, coding, billing, legal and quality purposes, however, safety and quality of patient care in surgery relies on documentation functioning as a shared communication tool among healthcare workers to facilitate continuity of care (Jawaid et al., 2008; Rogers et al., 2008). Using an observational approach to investigate how healthcare professionals used anaesthetic preoperative risk assessment forms, Harper et al.’s (1997)

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findings revealed multiple functions of the anaesthetic record. Anaesthetists used the form during anaesthetic delivery to serve as a written reference for critical reminders, to gather information for consideration and planning, and to assist with the verbal passing of information. Thus, anaesthetists documented information purely for their own context and purpose, frequently omitting information without regard for other functions such as audit and patient risk stratification (Harper et al., 1997). These omissions in information were not evaluated for any communicative or patient effects. Addressing the comprehension of pathology reports, Powsner et al. (2000) investigated how 34 general attending surgeons and trainees interpreted information in printed reports through questionnaires. Surgeons were presented with short clinical scenarios and a pathology report before being required to answer questions under open book test conditions. The researchers found discordance between surgeons’ interpretations and pathologists’ intended meanings in pathology reports for 30% of the time, signifying the document was regularly failing in its communicative function, potentially precipitating medical errors. This study, however, was conducted at a surgical conference and not in a hospital. This is a noteworthy limitation as in the clinical setting surgeons have the opportunity to seek clarification with reporting pathologists. 3.5. Documents that coordinate verbal communication Preoperative checklists are documents that create opportunities to formalise and standardise work activities and to invite verbal interaction and information exchange among multidisciplinary surgical team members (Lingard et al., 2008). This dedicated opportunity to communicate enables surgical team members to align goals, fill knowledge gaps and plan multidisciplinary care for surgical procedures (DeFontes and Surbida, 2004; Lingard et al., 2008). Following the introduction of preoperative checklists, a survey and retrospective review conducted by DeFontes and Surbida (2004) found a reduction in wrong site surgery (300%), improved employee satisfaction (19%), a reduction in nursing staff turnover (16%) and an improved perception of operating room safety climate from ‘good’ to ‘outstanding’. Nonetheless, these researchers (DeFontes and Surbida, 2004) did not objectively assess how communication was improved to bring about these results. Taking up this challenge, Lingard et al. (2008) carried out a prospective pre and post intervention study to assess if surgical team briefings using a preoperative checklist improved operating room communication. Communication among surgical team members that was inaccurate in its content, did not include all relevant team members, occurred too late, or did not accomplish its purpose, were recorded as communication failures by trained observers using a validated observational scale designed to evaluate team communication in the operating room (Lingard et al., 2006, 2008). The results revealed that the checklist intervention quantifiably reduced the mean number of communication failures per procedure from 3.95 to 1.31

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(p < 0.001), as well as reducing the visible negative consequences of communication failure such as delay, inefficiency and tension (Lingard et al., 2008). While Lingard et al.’s (2008) results were confined to a single institution, Haynes et al. (2009) implemented a surgical safety checklist in 8 hospitals across the globe (n = 7688). Following the checklist introduction the death rate dropped from 1.5% to 0.8% (p = 0.003) and the inpatient complications from 11% to 7% (p < 0.001) in surgical patients (not undergoing cardiac surgery). Similar reductions in morbidity and mortality were reproduced when Weiser et al. (2010) introduced the same checklist to patients undergoing urgent surgical procedures in a comparable global population (n = 1750). The complication rate fell from 18.4% to 11.7% (p = 0.0001) and the death rate dropped from 3.7% to 1.4% (p = 0.0067) following the checklist introduction. While these results suggest that preoperative checklist documents have a role in averting communication failure among surgical team members that may advantage patient outcomes, Lingard et al.’s, Haynes et al.’s and Weiser et al.’s research is focused only within the intraoperative domain of the perioperative pathway. 4. Discussion The quality evaluation undertaken for all papers included in this literature review revealed variable quality for reporting accuracy, comprehensiveness and transparency of the research conducted. Overall, papers reporting on pre and post intervention studies attained consistently high quality scores (85–88%), as did most survey studies (70–88%). Some researchers, however, when reporting on how the survey was conducted, imparted insufficient detail on sample selection and data collection. For observational studies, inconsistency in quality reporting was evident, as quality scores ranged from 60% to 90%. In particular, information on participant eligibility, selection and characteristics was often missing, as was information addressing potential sources of bias. Papers reporting on audits and reviews of records, which represented the bulk of reviewed papers, also showed variability in quality scores (40–87%). Of the papers with low quality scores, information on limitations such as factors affecting internal and external validity, were lacking. Papers with high quality scores reporting on audits and reviews of records, acknowledged and explored limitations pertaining to the study, suggested steps to modify the study for improved future performance and offered suggestions for the direction of further research. Thus to improve the quality of future research in the area of documents and documentation across the perioperative pathway, researchers must explicitly report and clarify study limitations, particularly potential sources of bias relevant to the study, and also ensure details regarding data collection and sampling are transparent. This literature review draws attention to multiple problems with documents and documentation used by healthcare professionals across the perioperative pathway. These results are based on the conduct of more quantitative than qualitative research. Interestingly, despite its strong association with the development of sentinel and

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adverse patient events (AIHW and ACSQHC, 2008; JCAHO, 2007), communication through documents and documentation has not been extensively explored. Research that involved actually examining communication and patient outcomes attributable to communication failure from documents and documentation is lacking, as many studies simply alluded to potential consequences or to recommendations to enhanced communication. Accordingly, greater research into the causes of communication failure through documents and documentation and how it is linked to patient outcomes across the perioperative pathway is urgently needed. While the findings of this literature review are relevant to the perioperative environment, research that specifically focuses on how documents are used across all domains of the perioperative pathway are lacking. The approach to investigating documents has been overwhelmingly confined to a single domain of the perioperative pathway, in particular, the intraoperative period. Conducting research within isolated domains fragments the continuum of the perioperative pathway and can consequently neglect to address how documents and documentation generated in one domain of the perioperative pathway can cause communication failures in another part of the perioperative pathway. From this point, the importance of documentation availability and timeliness also arises. The relentless and rapid movement of surgical patients through the preoperative pathway highlights the importance of documentation keeping up with the patient; yet, the research is scant on this topic. This is an area worthy of greater attention, as no matter how comprehensive patient documentation is, if it is not available, then it is not meeting its communicative functions, and the delivery of safe and quality patient care is likely to be compromised. The results of this literature review highlight a number of important points for healthcare professionals to consider when using documents and documentation in practice. Numerous researchers draw attention to poor quality documentation (Burda et al., 2005; Driscoll et al., 2007; ElGhrably and Fraser, 2008). Thus a key clinical consideration for healthcare professionals must be aspiring to documentation accuracy and completeness. In part, this may be achieved through the design of documentation, as noted by Marco et al. (2003) and Takata et al. (2001), the design of documentation can impact on information captured. Active involvement of healthcare professionals in the design of documentation may assist to yield documentation formats that obtain and communicate information required by institutions and multidisciplinary healthcare professionals across the perioperative pathway. Documentation in the areas of accuracy and function is also revealed as problematic by this literature review. Similar to documentation quality, accuracy and functions of documentation are products of the time allocated to completing it, and the value that healthcare professionals assign to performing it (Butler et al., 2003; De Marinis et al., 2010; Junttila et al., 2000). As surgeons, anaesthetists and nurses predominantly accomplish perioperative documentation through discipline-specific patient records, this

focus may result in clinicians overlooking the shared communicative functions of documentation for a broader audience, as it is utilised by other healthcare professionals to elicit essential clinical information across the perioperative pathway. Accordingly, to emphasise the value of documentation, education to raise awareness on how different healthcare professionals use documentation in different domains of the perioperative pathway, may enhance their understanding of its communicative functions from diverse perspectives. Additionally, fostering an organisational culture that views documentation as a highly valued communication resource, supports healthcare professionals to achieve documentation that is functional, accurate and of high quality. In turn, an integrated multidisciplinary team approach to patient care is facilitated, as healthcare professionals rely on documentation to provide comprehensive patient information. Yet, to develop documentation into a valuable communication resource, its importance must be reflected in institutional policies that afford healthcare professionals the time to adequately perform documentation. Another key point this literature review underscores is the merit of preoperative checklists as documents that coordinate verbal communication (Haynes et al., 2009; Lingard et al., 2008; Weiser et al., 2010). An important implication arising from this finding is that the effect of reduced communication failure through the use of a document that coordinates healthcare professionals’ verbal communication, has rarely been explored outside the confines of the operating theatre and into the broader perioperative pathway. Approaching this literature review from a multidisciplinary perspective, generated more papers reporting on documentation accomplished by surgeon and anaesthetists, than by nurses. Although most nurses routinely perform documentation across the perioperative pathway, research into this nursing practice has not been extensively explored. As a result, this review reflects findings from the comparison and categorising of data collected from research performed by surgeons and anaesthetists more so than nurses. Furthermore, of the research designs reviewed for this paper, audits and review of records were overly represented. Consequently the findings of this literature review reflect results of investigations conducted by quantitative methods more so than those then those conducted by qualitative methods. Finally, a substantial share of papers reviewed, examined the quality of documentation. This generated greater proportions of information for findings in the area of quality, as compared to the areas of documentation design, purpose, accuracy, and documents that coordinate verbal communication. Limitations to this literature review exist. Methodologically, a structured literature review, not a formal systematic review process, was undertaken. While 2 independent reviewers performed the analysis and quality evaluation, a single reviewer selected the key papers for inclusion. It is also possible that the key words used did not identify all the published research on communication, documentation and documents across the perioperative pathway. Further, conference papers

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and other unpublished sources were not accessed for inclusion in this review. Additionally, while peer reviewed journals pertaining to healthcare research were searched, it is possible that related research exists in non-healthcare publications. Finally, only papers contained in journals published in the English language were considered. 5. Conclusion Patients pose a major challenge to the delivery of continuous surgical care, as they transit through the care of multiple healthcare professionals from varying disciplines, as well as through multiple departments of the perioperative pathway. Accordingly, effective communication between clinicians is a critical factor in ensuring information is transferred smoothly and successfully. Documents and documentation are integral components of this communication process, acting as tools for capturing, sharing, exchanging and disseminating information. Any document or documentation deficient in detail, currency, accuracy, availability or its function, can compromise information transfer and the coordination of patient care. The effect of such communication failure extends to all attending healthcare professionals accessing the documents or providing documentation across the perioperative pathway, with the patient ultimately enduring potentially devastating consequences. To continue to improve the safety and quality of patient care, future research should focus on how healthcare professionals from all disciplines use documents and documentation to communicate as the patient travels through the continuum of the perioperative pathway. Such an investigation would address the different functions, expected quality and problems encountered with the communicative functions of documents and documentation, from a multidisciplinary and multidepartment perspective. Conflict of interest No conflict of interest exists. Acknowledgments to the Australian Research Council linkage project grant and Eastern Health for providing financial support. These funding bodies were not involved in the conduct of the research. References Al Hussainy, H., Ali, F., Jones, S., McGregor-Riley, J., Sukumar, S., 2004. Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma. Injury 35 (11), 1102–1106. Australian College of Operating Room Nurses (ACORN), 2006. Standards, Guidelines and Policy Statements. Australian College of Operating Room Nurses Ltd., Sydney. Australian Institute of Health Welfare (AIHW), Australian Commission on Safety Quality in Health Care (ACSQHC), 2008. Sentinel Events Program Annual Report 2007–08. Rural and Regional Health and Aged Care Services, Victoria Government Department of Human Services, Melbourne. Baigrie, R., Dowling, B., Birch, D., Dehn, T., 1994. An audit of the quality of operation notes in two district general hospitals. Annals of the Royal College of Surgeons of England 76 (1 Suppl.), 8–10. Barritt, A., Clark, L., Cohen, A., Hosangadi-Jayedev, N., Gibb, P., 2010. Improving the quality of procedure-specific operation reports in orthopaedic surgery. The Royal College of Surgeons of England 92, 159–162.

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