[Quality of process records in the surgical area and possible consequences for patient safety]

The objective is to detect defects in the completion of surgical records (omissions/illegibility), assess their severity and potential consequences, and design improvement strategies.

The clinical records of nursing and anaesthesia (paper-based) and surgical records (electronic) for major surgical procedures performed over a three-month period at Martorell Hospital (Spain) were reviewed. Deficiencies (omissions and illegibility) were identified, and variables with completion deficiencies in more than 50% of the records or with potential impact on patient safety were selected. A panel of experts used a questionnaire to assess severity (high = 70-89%, very high = >90%) and possible consequences (pre-, intra-, post-surgical, and administrative), and proposed for improvement measures.

Medical records from 491 patients were analysed. Illegibility was almost non-existent, except for four variables (=10%). The overall completion rate was 98%. Forty-three variables with defects in >50% of records or with potential impact were included in the questionnaire, which was sent to 29 experts. The reliability of their responses was very high (a=0.995; intraclass correlation coefficients: individual=0.880 and average=0.995). Omissions of nearly all variables were considered of high or very high severity, with postoperative consequences outweighing intraoperative ones. Face-to-face team training and record adaptation were the most frequently recommended improvement strategies.

Surgical records show serious to very serious omissions with potential postoperative consequences for patient safety. Simulation-based training was considered the most effective tool for improvement.