Observational studyANZ journal of surgery2025
Lost in transcription - how accurately are we documenting the surgical ward round?
Observational study in ANZ journal of surgery, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
1 citing paper in PubMed.
- A Simple Solution for a Complex Problem: The "Sterile Cockpit" to Improve Ward Rounds.World journal of surgery · 2025Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
10 authors.
Funding
Abstract
backgroundWard rounds are crucial to providing high-quality patient care in hospitals. Ward round quality is strongly linked to patient outcomes, yet ward round best practice is severely underrepresented in the literature. Accurate and thorough ward round documentation is essential to improving communication and patient outcomes.
methodsA prospective observational cohort study was performed by reviewing 135 audio-visual recordings of surgical ward rounds over 2 years at two hospitals. Recordings were transcribed, and an external reviewer stratified discussion points as Major, Minor, or Not Significant. Discussion was compared to the ward round note to assess the accuracy of documentation based on bedside discussion. The primary endpoint was the accuracy of Major discussion in the patient case notes. Secondary objectives involved investigating variables that may have impacted accuracy (e.g., patient age, sex, length of stay in hospital, and individual clinicians).
resultsNearly one third (32.4%) of important (Major) spoken information regarding plans and patient care in the ward round was omitted from the patients' written medical record. Further, 11% of patient case notes contained significant errors. Patient age (P = 0.04), the day of the week on which the ward round occurred (P = 0.05) and who the scribing intern was (P ≤ 0.001) were found to impact documentation accuracy. There was a large variation in interns documenting ability (35.5%-88.9% accuracy).
conclusionsThis study highlighted that a significant portion of important discussion conducted during the ward round is not documented in the case note. These results suggest that system-wide change is needed to improve patient safety and outcomes.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.