WHO Safety Research Articles

Comparing compliance with the WHO surgical safety checklist and complication rates in gynecologic surgery between day and night shifts

PurposeAt least half of surgical complications can be avoided by using surgical checklists. However, universal implementation and compliance have been reported as being variable. Patients undergoing urgent surgical intervention are at increased risk for complications. The aim of this study was to evaluate the checklist compliance together with the complication rate during day and night shifts in a European University hospital.Methods51 and 52 consecutive patients who had surgery during day and night shifts were included. The primary outcome measures were compliance and completeness of the WHO safety checklist. The occurrence of postoperative complications was investigated.ResultsThe analysis included 103 surgical procedures. The mean compliance rate of use was 93% and the mean completeness rate was 22%. After operations were broken down by day or night shift, we found that checklists were less often available in night shifts compared to day shifts. The completeness of the checklist and the occurrence of postoperative complications did not differ between day and night shifts.ConclusionThis study reports worse checklists availability in night shifts when compared to day shifts, but complication rates did not increase. Further studies are warranted to investigate postoperative complication rates together with checklist compliance in day versus night shifts.

Participatory mental health interventions in low-income and middle-income countries: a realist review protocol

IntroductionThe launch of the Movement for Global Mental Health brought long-standing calls for improved mental health interventions in low-and middle-income countries (LMICs) to centre stage. Within the movement, the participation...

HEAVY METAL CONTENTS OF SACHET WATER IN GOMBE, NIGERIA.

Background: The provision of adequate clean drinking water is a basic human need in every society. In Nigeria, like many developing countries, the provision of clean drinking water is not adequate. The introduction of sachet water is seen by many as a solution to the problem. This is because it is affordable where more than a litter of it is sold at ten Naira or even less. The availability and affordability of sachet water have made it a preferred choice for most people despite questions being raised about the purity and potential toxicity. Objectives: To evaluate the heavy metal contents of sachet water in Gombe, Nigeria. Methodology: Forty samples of sachets water were bought randomly from the streets of Gombe and were analyzed for heavy metals content (lead, cadmium, mercury, arsenic and nickel) using Atomic Absorption Spectrophotometer (AAS). The data obtained were analyzed for frequencies and percentages for qualitative data and minimum and maximum for quantitative data using the system for statistical package for the social sciences (SPSS) version 20.00 for windows. Results: None of the sachet water samples had the date of manufacture or expiry date while about 23% had no National agency for food and drug administration and control (NAFDAC) registration numbers. All the samples had lead levels above the WHO safety limits of 0.01mg/L. Mercury, cadmium and arsenic levels were higher than the safety limits in 23%, 15% and 5% of the samples respectively. No nickel was detected in all the samples. Conclusion: The majority of the sachet water in Gombe is contaminated with heavy metals lead, mercury and cadmium in concentrations above the WHO safety limits. Processes of water purification should be put in place to reduce the heavy metal contents of sachet water in Gombe.

A STUDY ON THE WORKING OF BLOOD BANK

Blood is an important drug in times of critical medical ailments during this pandemic. Plasma-related therapy (PR) is an efficient way to treat critical patients that decrease the rate of hospitalizations by intensive care. In the meantime, Plasma Bank reviewed the Blood Transfusion Systems in India, which lies at the root of Plasma Bank network development. An analysis report on the blood banks in India has been presented to improve the blood transfusion systems in India. For this study we take into account the blood bank data available on the Indian government's data portal data.gov.in. The study concludes that India's blood banks are not proportionate to the population of the States and Union territories and are non-uniform in distribution. In India, blood storage units are not a proposal for blood banks that can lead to blood wastage. In order to facilitate recovery plasma therapy during the current crisis, blood bank distributed necessary machines to NON- NACO Blood Bank too.
 The convalescent plasma therapy was considered to be one of the treatments for SARS-CoV-2 during this pandemic due to serious acute respiratory syndrome coronavirus, but current evidence shows that convalescent plasma does not improve survival or reduce the need for mechanical ventilation (WHO guidelines 7th December 2021). Though over the past two decades, convalescent Plasma Therapy (CP) has also proved to be one of the efficient means for quick recovery in the treatment of SARS-CoV-1, MERS-CoV. This involves collecting plasma containing the COVID antibodies from the recovered people to treating infected people. The retrieved Sars-Cov-2 infected between 18-60 years can donate 500-600 cc of plasma collected in a therapeutic apheresis device after 14 days. This therapy is considered to be an effective method for dealing with critical patients, among several studies relating to Convalescent Plasma (CP) therapy, which can reduce the high demand rate of intensive care hospitalizations during this pandemic. In India, Delhi's government has taken steps to establish a plasma bank to help patients in Delhi/NCR, as COVID-19 cases are exponentially growing. This plasma theory was approved by the Indian Government to save people's lives from serious health problems. But as off now owing to the current studies and WHO latest guidelines (7th December 2021) convalescent plasma does not hold any relevance in covid cases as convalescent plasma does not improve survival or reduce the need for mechanical ventilation.
 The Blood transfusion service (BTS) is an important unit. During blood transfers and donations that save lives and improve health, the National AIDS Control Organization has increased awareness and implementation of current infectious markers (T.T.I). India ranks third in HIV/AIDS, which is closely related to blood and healthcare practices, as the WHO country cooperative strategy reports. The report of WHO statistical survey suggests that over 95 percent of countries with high income have blood self-sustainability, while middle and lower national blood requirements do not meet their own needs. Blood donation camps throughout the countries should be organized regularly to meet the daily needs of the patients for their blood.
 The blood banks in India have been supported by NACO, the Health Ministry, the Indian government as well as well as some of the Non-NACO blood banks. In order to deliver the equipment, consumables, labor, and capacity building, NACO's efforts had strengthened all the blood banks across the country. There are three sources to get blood such as walk-in licensed blood banks, blood donation camps and mobile blood camps. Maintaining the self-sustainability of blood supplies and blood needs is one of the main issues for the government in most countries. In 2013, only high-income WHO nations reported a 95% self-sustainability of their use in the WHO safety and availability fact sheets. Non-sustainability problems in low- and middle-income countries are due to lack of motive and poor perception of voluntary blood donations and waste of blood and manual errors could another be the reason behind it, and due to which the blood requirement is not met. There are currently so many challenges that has prevented the donation of plasma among patients which could be result of fear of COVID-19. During this pandemic crisis the study was carried out with the objective of improving the blood transfusion systems in India. This study presents the analysis report on India's blood banks in accordance with the geographical distribution, population and facilities such as apheresis and CBSU.

The importance of a safety checklist and strategic rest breaks in gynaecological laparoscopy

This study focuses on the importance of a safety checklist for gynaecological laparoscopic surgeries. Although several general safety checklists are used in practice (e.g.: The WHO Safety Checklist), there is no dedicated safety checklist for gynaecological laparoscopic surgeries. Our aim is to introduce a safety checklist dedicated to gynaecological laparoscopy. It is based on our experience in performing various gynaecological laparoscopic surgeries in a tertiary care center with a substantially high workload. It has been compiled after studying the complications occurring in areas covered by the aforementioned checklist. We present data from 776 cases performed over 4 years at the Professorial Unit in Obstetrics and Gynaecology affiliated to the University of Sri Jayewardenepura, at Colombo South Teaching Hospital, Kalubowila, Sri Lanka. The mean surgical time and complications associated with patient positioning have been assessed. Complications associated with the areas assessed were found to be of low incidence. However, we believe that these can be reduced further by the introduction of a checklist specifically tailored for gynaecological laparoscopy.

Assessing, grading, and reporting intraoperative adverse events during and after surgery.

Intraoperative adverse events (iAEs) are under-reported, have poorly standardized nomenclature, and are plagued by barriers to reporting and cultural acceptance. Not surprisingly, although surgeons are willing to report iAEs, they often under-report these events, especially those of lower severity, owing to perceived clinical insignificance1. Attempts to overcome reporting deficits with surgical black-box systems, otherwise known as medical data recorders, have continued to receive pushback despite the potential benefits for quality improvement2,3. Until these systems gain further traction, integration of iAE reporting into the sign-out portion of the WHO safety checklist might be a useful aide-memoire4,5. Barriers to reporting, such as institutional, emotional, and litigious concerns, remain challenging to overcome6. Further, the intransigent blame culture continues to detract from a universally shared goal of improved patient safety6. The, regrettably, common lack of institutional support for litigation concerns, and an absence of clear definitions of what should be reported and how to report, might be surmountable with improved awareness of available resources. There are several iAE classification systems available, including, but not limited to: Modified Satava, the iAE severity classification system (Massachusetts General Hospital), the European Association of Surgical Endoscopy classification7,8, intraoperative adverse incident classification (European Association of Urology)9, and the classification of intraoperative adverse events (ClassIntra®)10. These systems are universally available and can be used to clearly delineate what constitutes an iAE. However, with the exception of ClassIntra®, many of these systems have yet to be validated and are known to have high inter-rater variability10–13. In the absence of a single best system, a vital first step is to record and grade iAEs prospectively, regardless of which system is chosen, so that we can move on to understanding the real-world implications of iAEs. Although these classification systems are useful for grading iAEs, they stop short of providing guidelines for reporting in publications or daily practice.

Heavy Metal contents of sachet Water in Gombe, Nigeria.

ABSTRACT Background: The provision of adequate clean drinking water is a basic human need in every society. In Nigeria, like many developing countries, the provision of clean drinking water is not adequate. The introduction of sachet water is seen by many as a solution to the problem. This is because it is affordable where more than a litter of it is sold at ten Naira or even less. The availability and affordability of sachet water have made it a preferred choice for most people despite questions being raised about the purity and potential toxicity. Objectives: To evaluate the heavy metal contents of sachet water in Gombe, Nigeria. Methodology: Forty samples of sachets water were bought randomly from the streets of Gombe and were analyzed for heavy metals content (lead, cadmium, mercury, arsenic and nickel) using Atomic Absorption Spectrophotometer (AAS). The data obtained were analyzed for frequencies and percentages for qualitative data and minimum and maximum for quantitative data using the system for statistical package for the social sciences (SPSS) version 20.00 for windows. Results: None of the sachet water samples had the date of manufacture or expiry date while about 23% had no National agency for food and drug administration and control (NAFDAC) registration numbers. All the samples had lead levels above the WHO safety limits of 0.01mg/L. Mercury, cadmium and arsenic levels were higher than the safety limits in 23%, 15% and 5% of the samples respectively. No nickel was detected in all the samples. Conclusion: The majority of the sachet water in Gombe is contaminated with heavy metals lead, mercury and cadmium in concentrations above the WHO safety limits. Processes of water purification should be put in place to reduce the heavy metal contents of sachet water in Gombe. Keywords: Gombe, heavy metals, sachet water, toxicity

Spatial distribution of manganese in groundwater and associated human health risk in the southern part of the Bengal Basin.

The scarcity of arsenic and iron-free safe drinking water is an alarming issue in the southern part of the Bengal Basin. The objectives of the present study were to investigate the spatial distribution of manganese (Mn) concentration in the shallow and deep groundwater and its associated health risks for the children and adults of entire southern Bengal Basin. The Mn concentration in the groundwater varied from 0 to 5.4 mg/L with an average value of 0.47 mg/L that exceeded the WHO's and Bangladesh drinking water guideline values of 0.4 and 0.1 mg/L, respectively. Mn concentration in the shallow wells overrode the deep ones. About 23% of the shallow wells and 11% of deep wells exceeded the WHO's safety limit of Mn concentration for human health. The human health risk related to Mn contamination was estimated by computing the average daily dosage (ADD) and hazard quotient (HQ) values for children and adults. The average computed HQ values found 0.108 and 0.099 for children and adults, respectively. The HQ values delimitated that children are posing a higher risk compared to the adults for the shallow wells. Deep wells were found risk-free for both children and adults. The areal coverage of shallow wells with HQ values > 1 was minimal compared to the total study area and covered only a small portion of Patuakhali and Barguna districts. The rest of the site does not pose any health risk due to Mn contamination for children and adults.

Religious Support as a Contribution to Face the Effects of Social Isolation in Mental Health During the Pandemic of COVID-19.

Coping with the COVID-19 pandemic has required measures to contain the contagion, including social isolation. However, this and other factors have caused mental health problems, both in patients and health professionals and in family members or asymptomatic population. Religious support can be an ally for this type of confrontation. In the case of the COVID-19 pandemic, spiritual/religious care has been restricted and insufficient. When accessible to patients and frontline professionals, they are offered by virtual means, almost always by recorded media and made available in bulk. This essay argues, based on references in the areas of psychology, psychoneuroimmunology, biosafety, and military, that the face-to-face and personalized relationship between religious leaders, patients, health professionals, family members, and faith communities is as essential as possible for the dignified treatment victims, referral to spiritual needs and resilience of society, in addition to contributing to the improvement of the immune response of all. Practical examples are cited in the areas of military chaplaincy and hospital civilian chaplaincy. The essay also proposes the adoption of protocols already published by WHO and other safety measures such as the use of robotics and the recruitment/training of mass chaplains. In addition to contributing to the improvement of COVID-19 pandemic coping processes, the study also contributes to improving the delivery of spiritual/religious care as an ally to physical and mental, individual, and collective health.

Introduction of a safety checklist for gynecological laparoscopy

This study focuses on the importance of a safety checklist for gynecological laparoscopic surgeries. There is no dedicated safety check list for gynecological laparoscopy although several general safety checklists are used in practice. (e.g. WHO safety check list). The aim was to introduce a safety check list dedicated to gynecological laparoscopy. This check list is based on our experience in performing gynecological laparoscopy in a tertiary care centre with a high workload. This check list is introduced after studying the complications occurring in areas covered by the check list. Present data from 776 cases performed over 4 years at professorial unit in obstetrics and gynecology, university of Sri Jayewardenepura, Colombo South teaching hospital, Kalubowila, Sri Lanka. Mean surgical time and complications associated with patient positioning were assessed. Complications associated with the areas assessed were found to be low. However, it is belief that these can be further reduced by the introduction of a check list specifically designed for gynecological laparoscopy.

Managing the COVID-19 pandemic in poor urban neighborhoods: The case of Accra and Johannesburg.

Without a vaccine, practicing social distancing and protective hygiene are the most effective measures to curb the spread of COVID-19. In order to understand how the urban poor mitigate their risk of infection, we conducted a survey with more than 1,400 poor households in two of the African cities with the most COVID-19 infections, Accra and Greater Johannesburg, early in the pandemic, during lockdowns of public life. We find that many of the urban poor already engage in the appropriate hygienic behavior and follow social distancing rules. However, despite citywide lockdowns, about 25-40% of people still report attending large gatherings, 10-20% report receiving guests at home, and 30-35% report leaving the house more than once per week. Lack of cooperation with governmental regulations seems to be more related to a lack of infrastructure or poverty rather than unwillingness to engage in behavioral change. Interestingly, even with the stricter lockdown in South Africa, people are at least equally likely to deviate from social distancing rules. Our results indicate that more South African respondents perceive their government's actions as too extreme and underestimate COVID-19 cases in their country. About half of the sample in both countries report knowing (mainly through TV) about current COVID-19 case numbers. Most participants know that coughing is a symptom, but only half mention fever and difficulty breathing, and very few people mention tiredness. Ghanaians seem to be somewhat better informed. While lack of information is an issue, misinformation appears to be limited. We conclude that a costly shutdown of public life is only effective-and might even be prevented-with a well-informed population, who perceives their government's actions as appropriate and who has access to the infrastructure required to follow WHO safety regulations.

Characterisation of fungal and bacterial dynamics in an active green wall used for indoor air pollutant removal

Indoor air quality (IAQ) is of growing public health concern which has prompted the use of plants to phytoremediate air pollution in interior spaces. Active green walls are emerging as a means of reducing indoor contaminants and have demonstrated efficacy comparable to conventional air filtering technologies. However, the use of active airflow through organic substrates has the potential to emit bioaerosols into the surrounding environment, where the potential risk to human health is largely unknown. In this study, we demonstrate that two indoor green walls (with and without active airflow) contribute significantly to the ambient fungal load, however concentrations remained well below WHO safety guidelines. Bacterial dynamics within the rhizosphere/substrate of the operational botanical biofilters displayed variability across plant species. Phyla-wide distribution generally aligned with previous literature; however, differences from those previously reported were observed at the genus level, possibly due to geographic location, substrate composition, or plant species selection. Targeted assessment of Legionella aerosol contamination, an under-addressed potential pathogen for these active systems, yielded no positive identification during the sampling period. We conclude that active green walls host a unique bacterial profile and do not emit harmful levels of fungal propagules or pose significant risk of aerosolised Legionella species, provided systems are well monitored and maintained.

Body Mass Index is Associated with Arsenic Metabolites in three studies in Bangladesh

TPS 636: Metals and health 2, Johan Friso Foyer, Floor 1, August 28, 2019, 3:00 PM - 4:30 PM Worldwide, over 140 million individuals are exposed to arsenic (As) in drinking water above 10 μg/L, the WHO safety standard. The methylation of ingested arsenic (As) forms mono-methyl (MMA) and dimethyl (DMA) arsenicals, facilitates urinary As (uAs) elimination, and potentially reduces As toxicity. Higher MMA% in urine has been associated with a greater risk for cardiovascular disease, skin lesions, and various cancers. Conversely, lower MMA% in urine has been associated with increased risk of diabetes-related outcomes in populations from the US and Mexico. Methods. To estimate the association between body mass index (BMI) and uAs metabolites in Bangladeshi populations this study examined a total of 1606 (783 male and 823 female) participants from the Folic Acid and Creatine Trial (FACT), Folate and Oxidative Stress (FOX), and the Health Effects of Arsenic Longitudinal (HEAL) adolescent ancillary studies. Multiple linear regression models were used to analyze the relationship between BMI and uAs metabolites. Results. uAs metabolites were associated with BMI in females in all three studies. For instance, the adjusted mean difference (95% confidence) in BMI for a 5% difference in MMA% and DMA% for the FACT study was -0.74 (-1.24, -0.25) kg/m2 and 0.46 (0.18, 0.75) kg/m2, respectively. Across all studies, lower MMA% was associated with higher BMI levels in females. Conclusions. While the reason underlying the sex-specific findings is unclear, we speculate that it may be related to differences in body fat and/or hormone levels. These data are consistent with negative associations between MMA% and diabetes-related outcomes in previous studies. The current analyses were cross-sectional and reverse causality is possible. Future studies are needed to evaluate these sex-differences, especially during adolescence as it is a period of hormonal change, and determine whether the relationship between BMI and As methylation influences risk for As-related health outcomes.

From box ticking to the black box: the evolution of operating room safety.

Efforts to improve the safety of patients in the operating room have focused on mitigating harm through the standardization of system, team, and human level factors. This article highlights existing and future methods for enhancing safety in the perioperative setting, and the theory and principles that underpin them. Evidence surrounding the development and implementation of select surgical safety interventions is discussed. Work in human factors and engineering that has inspired safety interventions such as the WHO Safety Checklist, and more recently operating room recorders, represents a movement away from traditional, retrospective or reactive methods of studying surgical safety, to prospective and proactive ones. Future work will examine the effectiveness of these interventions for improving patient outcomes and minimizing iatrogenic harm.

Gynecology healthcare professionals towards safety procedures in operation rooms aiming to enhanced quality of medical services in Greece

PurposeThe purpose of this paper is to investigate the attitudes of healthcare professionals in Greece toward safety practices in gynecological Operation Rooms (ORs).Design/methodology/approachAn anonymous self-administered questionnaire was distributed to surgical personnel asking for opinions on safety practices during vaginal deliveries (VDs) and gynecological operations (e.g. sponge/suture counting, counting documentation, etc.). The study took place in Hippokration Hospital of Thessaloniki including 227 participants. The team assessed and statistically analyzed the questionnaires.FindingsAttitude toward surgical counts and counting documentation, awareness of existence and/or implementation in their workplace of other surgical safety objectives (e.g. WHO safety control list) was assessed. In total, 85.2 percent considered that surgical counting after VDs is essential and 84.9 percent admitted doing so, while far less reported counting documentation as a common practice in their workplace and admitted doing so themselves (50.5/63.3 percent). Furthermore, while 86.5 percent considered a documented protocol as necessary, only 53.9 percent admitted its implementation in their workplace. Remarkably, 53.1 percent were unaware of the WHO safety control list for gynecological surgeries.Originality/valueMost Greek healthcare professionals are well aware of the significance of surgical counting and counting documentation in gynecology ORs. However, specific tasks and assignments are unclear to them. Greek healthcare professionals consider surgical safety measures as important but there is a critical gap in knowledge when it comes to responsibilities and standardized processes during implementation. More effective implementation and increased personnel awareness of the surgical safety protocols and international guidelines are necessary for enhanced quality of surgical safety in Greece.

National Dietary Guidelines of Greece for children and adolescents: a tool for promoting healthy eating habits.

Dietary guidelines are an essential policy tool for facilitating optimal dietary patterns and healthy eating behaviours. We report: (i) the methodological approach adopted for developing the National Dietary Guidelines of Greece (NDGGr) for Infants, Children and Adolescents; and (ii) the guidelines for children aged 1-18 years. An evidence-based approach was employed to develop food-based recommendations according to the methodologies of the WHO, FAO and European Food Safety Authority. Physical activity recommendations were also compiled. Food education, healthy eating tips and suggestions were also provided. The NDGGr encompass food-based nutritional and physical activity recommendations for promoting healthy dietary patterns and eating behaviours and secondarily to serve as a helpful tool for the prevention of childhood overweight and obesity. The NDGGr include food-based recommendations, food education and health promotion messages regarding: (i) fruits; (ii) vegetables; (iii) milk and dairy products; (iv) cereals; (v) red and white meat; (vi) fish and seafood; (vii) eggs; (viii) legumes; (ix) added lipids, olives, and nuts; (x) added sugars and salt; (xi) water and beverages, and (xii) physical activity. A Nutrition Wheel, consisting of the ten most pivotal key messages, was developed to enhance the adoption of optimal dietary patterns and a healthy lifestyle. The NDGGr additionally provide recommendations regarding the optimal frequency and serving sizes of main meals, based on the traditional Greek diet. As a policy tool for promoting healthy eating, the NDGGr have been disseminated in public schools across Greece.

If transversus abdominis plane blocks are to be used in laparoscopy then the gynaecologist is best placed to administer them.

The role of transabdominal plane (TAP) blocks in laparoscopic surgery is unclear, and their implementation is generally left to the discretion of the anaesthetist. The anaesthetist attempts to interrupt sensory innervation across several dermatomes by instilling local anaesthetic below the fascial plane between the internal oblique and the transverse abdominis muscles. The technique may involve one or two entry points on each side of the abdomen. The ‘blind’ TAP block relies upon orientation using superficial anatomical landmarks and a ‘double pop’ sensation indicating the needle is sited correctly. Inadvertent visceral injuries have been reported as well as suboptimal placement in the majority of patients and so visualisation with ultrasound to guide needle placement has been advocated (McDermott et al. BJA 2012;108:499–502). However, the excellent visualisation of the abdominal cavity provided by laparoscopy has promoted laparoscopically delivered TAP blocks. Randomised controlled trials (RCTs) have evaluated TAP blocks across surgical practice and systematic evidence syntheses have found them to be associated with modest improvements in overall quality of recovery and corresponding reductions in postoperative pain up to 24 hours postsurgery and requirements for analgesia (Brogi et al. Can J Anaesth 2016;63:1184–96). Most data pertaining to the impact of TAP blocks on recovery from laparoscopic surgery have come from trials involving laparoscopic cholecystectomy. Data specific to gynaecological surgery are scarce, although two small RCTs evaluating ultrasound-guided TAP blocks in laparoscopic hysterectomy have been conducted, albeit with conflicting results (Kane et al. Am J Obstet Gynecol 2012;207:419.e1–5; De Oliveira GS Jr et al. Obstet Gynecol 2011;118:1230–7.). The study in BJOG by R Kargar et al. (BJOG 2019;126:647–54) reports an RCT comparing laparoscopic TAP blocks with standard port-site infiltration of local anaesthetic and placebo in women undergoing complex laparoscopic endometriosis surgery. A benefit of laparoscopically deployed TAP and port-site blocks was shown compared with placebo in pain relief up to 12 hours following surgery. However, laparoscopic TAP blocks were no more effective than conventional port-site anaesthesia. The investigators missed an opportunity to evaluate the cumulative effect of combining TAP blocks with local port-site anaesthetic. So where are we now? Well, local port-site anaesthesia should be continued but further work is needed to ascertain who may benefit from TAP blocks whether used as an alternative or in combination with port-site blockade. Confounders, such as the type and duration of laparoscopic surgery, the size of ports, patient characteristics such as obesity, and local anaesthetic regimens need to be accounted for. In addition, the question of how TAP blocks should be delivered and by whom will be of interest; blindly or ultrasound-guided by the anaesthetist or under laparoscopic guidance by the gynaecologist? I suspect most surgeons are aware that the amount of time available on operating lists for actual surgery is diminishing because of prolongation of anaesthetic times and the requirement for WHO safety check lists. Peering through the anaesthetic room the eager, optimally prepared but time-poor surgeon can become deflated observing the anaesthetist manipulating a portable ultrasound machine in order to ‘line up’ the TAP blocks. I believe the opportunity to claw this time-consuming task from our enthusiastic anaesthetic colleagues will be welcomed by most surgeons! Dr Clark reports personal fees from Bayer, personal fees from Smith & Nephew, personal fees from Hologic, outside the submitted work. A completed disclosure of interest form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Implementation and evaluation of nationwide scale-up of the Surgical Safety Checklist.

BackgroundThe WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low‐income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally.MethodsThis study had a longitudinal embedded mixed‐methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty‐six hospitals received 3‐day multidisciplinary training and 4‐month follow‐up. Seventeen hospitals were sampled purposively for evaluation at 12–18 months. The primary outcome was sustainability of checklist use at 12–18 months measured by questionnaire. Secondary outcomes were CFIR‐derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups.ResultsAt 12–18 months, 86·0 per cent of participants (86 of 100) reported checklist use compared with 31·1 per cent (169 of 543) before training and 88·8 per cent (158 of 178) at 4 months. There was high‐fidelity use (median WHOBARS score 5·0 of 7; use of basic safety processes ranged from 85·0 to 99·0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76·7, 81·1 and 82·2 per cent before, and at 4 and 12–18 months after training respectively; P < 0·001). Acceptability, adoption, appropriateness and feasibility scored 9·6–9·8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully.ConclusionThis study shows successfully sustained nationwide checklist implementation using a validated implementation framework.

Analysis of arsenic in raw and cooked rice by atomic absorption spectrophotometer

Arsenic is a highly toxic and carcinogenic metalloid. Rice is a staple food that is widely used in the world, especially in Indonesia. Several studies have shown that arsenic level in rice is influenced by the environment and genetic differences of rice. The process of cooking in raw rice may reduce arsenic level in rice. The purpose of this research was to study the effect of cooking process using demineralized water and tap water on arsenic contents in rice. The samples used were white rice (Oryza sativa L), brown rice (Oryza rufipogon), “brown” rice (Oryza punctata) and black sticky rice (Oryza sativa var glutinosa) obtained from several traditional markets in Medan. The process of cooking was done using two types of water, namely demineralized (reverse osmosis; RO) water and tap water. The determination of arsenic level was carried out using atomic absorption spectrophotometer with argon-air flame at wavelength of 193.7 nm. The results showed that the highest arsenic content of 0.3061 mg/kg was found in red rice and the lowest arsenic level of 0.0693 mg/kg was found in white rice. Process of cooking with RO water and tap water reduced arsenic level in cooked rice. The highest reduction in arsenic content (21.93%) caused by cooking process using RO water and 11.40% caused by cooking with tap water. The result showed that the arsenic safety index in raw rice and cooked rice, based on the daily intake according to the excess cancer risk, exceeded the WHO safety standard.

Impact of violence against women on severe acute maternal morbidity in the intensive care unit, including neonatal outcomes: a case–control study protocol in a tertiary healthcare facility in Lima, Peru

IntroductionPreventing and reducing violence against women (VAW) and maternal mortality are Sustainable Development Goals. Worldwide, the maternal mortality ratio has fallen about 44% in the last 25 years, and for...