Surgical residents' perceptions of patient safety climate in Dutch teaching hospitals.

RATIONALE, AIMS AND OBJECTIVES: Explicit attention to patient safety during surgical training is needed to improve patient safety. A positive safety climate is associated with greater patient safety and is a requisite for safety teaching at the workplace. The Safety Climate Survey (SCS) measures perceptions of safety climate. This study aims to take a first step in validating the SCS for use among surgical residents in the Netherlands and to highlight opportunities for safety climate improvement through changes in surgical training in the Netherlands. It therefore assesses (1) if the SCS can be used to assess surgical residents' perceptions of the safety climate in Dutch teaching hospitals; and (2) how, according to SCS results, these residents perceive the safety climate in Dutch teaching hospitals. METHODS: In a cross-sectional study conducted in February 2011, a Dutch translation of the SCS was administered to all general surgical residents in the Netherlands. Face validity and internal consistency were assessed, as were overall mean, means per item and significant differences in means between different groups of respondents. RESULTS: In total, 306 of 390 (78%) residents completed the questionnaire. The SCS showed good face validity and internal consistency (Cronbach's alpha = 0.87). Residents reported an overall mean of 3.95 (standard deviation 0.51) out of a maximum score of 5.00, and 52% reported an overall mean of 4.00 or higher. Women and residents working in university hospitals gave significantly lower scores. Significant differences were also found among hospitals and among regions. Majority of the items scored less than 4.00. CONCLUSIONS: The SCS is potentially useful to measure surgical residents' perceptions of the patient safety climate in Dutch teaching hospitals. There is considerable room for improvement of the patient safety climate. Surgical training should include better feedback, formal patient safety teaching sessions at the workplace and specific attention to patient safety during the introduction in a new hospital, and supervisors should encourage surgical residents to report any patient safety concern they may have.

Possible solutions for barriers in incident reporting by residents.

RATIONALE, AIMS AND OBJECTIVES: Incident reporting can contribute to safer health care. Since the rate of reporting by residents is low, it is useful to investigate which barriers exist and how these can be solved. METHODS: Data were collected in a large teaching hospital in the Netherlands. The hospital uses a confidential, voluntary and web-based incident reporting system. Residents working in the hospital participated in focus group discussions to explore barriers and possible solutions. A grounded theory approach was used to analyse the transcribed discussions. RESULTS: In each focus group six to eight residents participated, resulting in a total number of 22 participants. After three focus group discussions, information saturation had been reached. Residents do not report all incidents because of a negative attitude towards incident reporting, because they experience a non-stimulating culture and because of a lack of perceived ability to report. Residents suggest several solutions to solve the barriers: providing the possibility to report anonymously, providing feedback, creating an incident reporting culture, simplifying the procedure, clarifying what and how to report, and exciting residents to report. CONCLUSIONS: Residents have useful suggestions to resolve the barriers that prevent them from reporting incidents. They include solutions that influence attitude, culture and perceived ability. These suggestions should be considered when making an effort to improve incident reporting by residents.

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study).

BACKGROUND: Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications.The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. METHODS/DESIGN: Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma > or = 3 cm, located between 1-15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment. Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures. Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group. DISCUSSION: The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas. TRIAL REGISTRATION NUMBER: (trialregister.nl) NTR1422.

Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence.

BACKGROUND: Anal inspection and digital rectal examination are routinely performed in fecal incontinent patients but it is not clear to what extent they contribute to the diagnostic work-up. We examined if and how findings of anal inspection and rectal examination are associated with anorectal function tests and endoanal ultrasonography. METHODS: A cohort of fecal incontinent patients (n=312, 90% females; mean age 59) prospectively underwent anal inspection and rectal examination. Findings were compared with results of anorectal function tests and endoanal ultrasonography. RESULTS: Absent, decreased and normal resting and squeeze pressures at rectal examination correlated to some extent with mean (+/-SD) manometric findings: mean resting pressure 41.3 (+/-20), 43.8 (+/-20) and 61.6 (+/-23) Hg (p<0.001); incremental squeeze pressure 20.6 (+/-20), 38.4 (+/-31) and 62.4 (+/-34) Hg (p<0.001). External anal sphincter defects at rectal examination were confirmed with endoanal ultrasonography for defects <90 degrees in 36% (37/103); for defects between 90-150 degrees in 61% (20/33); for defects between 150-270 degrees in 100% (6/6). Patients with anal scar tissue at anal inspection had lower incremental squeeze pressures (p=0.04); patients with a gaping anus had lower resting pressures (p=0.013) at anorectal manometry. All other findings were not related to any anorectal function test or endoanal ultrasonography. CONCLUSIONS: Anal inspection and digital rectal examination can give accurate information about internal and external anal sphincter function but are inaccurate for determining external anal sphincter defects <90 degrees. Therefore, a sufficient diagnostic work-up should comprise at least rectal examination, anal inspection and endoanal ultrasonography.