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Surgical Ward Round Quality and Impact on Variable Patient Outcomes.

To the Editor: We read with interest the recent article by Pucher et al that describes the relationship between surgical ward round (WR) quality in the high-dependency unit setting and clinical outcomes. This pragmatic observational study examined a vital aspect of inpatient care that had previously not been studied in detail. The association of poorquality WRs with delayed diagnoses and increased preventable complications is unsurprising. Simple, cheap, and easy-to-implement interventions such as WR checklists or proforma to improve the quality of patient review could lead to significant reductions in preventable morbidity. As such, the authors should be applauded for their efforts with this study. We would like, however, to point out a few significant limitations of this study. First, the subjects involved in this study were not blinded to the presence of the nonparticipating observer and as such an element of observer effect (the Hawthorne effect) is likely to have been introduced. This source of bias could have led to participants modifying their behavior in direct response to being observed, leading to nonrepresentative WR quality being analyzed in this study. Presentation of the prestudy period patient complication rate would have been helpful to examine the influence that this source of bias had on the results presented. In addition, the authors did not make suitable comparison or adjustment for the type of surgery that patients received to help support their finding that preventable complications were higher in the poorer quality WR group. For example, a higher rate of pulmonary complications in the poorer quality WR groups could be explained if these patients underwent more thoracoabdominal procedures than those in the good-quality WR group. A more detailed comparison of patient characteristics between the highand low-quality WR groups would have been desirable. Also, the use of a retrospective case note review to obtain data on patient complications is confounded by the likelihood that those performing a less thorough WR may also be less likely to record and document postoperative complications dili-