A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease

Common acquired causes of thrombosis in children

Compared to adults, venous thromboembolism in the pediatric population is a rare event. Cancer, cardiac disease, antiphospholipid antibodies, and indwelling catheters are established risk factors for thromboembolism in children. We examined the literature related to thrombophilia in children, childhood cancer and thrombosis, cardiac disease and thrombosis, and antiphospholipid antibody syndrome in children. Citations in identified articles yielded additional articles for review. We found that studies of acquired thrombophilia in children are limited. Current treatment for thromboembolism in children is based on adult data therefore optimal treatment in this population remains unclear.

Error rating tool to identify and analyse technical errors and events in laparoscopic surgery

Background

Surgical error analysis is essential for investigating mechanisms of errors, events and adverse outcomes. Furthermore, it provides valuable information for formative feedback and quality control. The aim of the present study was to design and validate a technical error rating tool in laparoscopic surgery.

Methods

The framework consisted of nine task groups and four error modes. Unedited videos of laparoscopic Roux-en-Y gastric bypass procedures were rated and analysed. The Objective Structured Assessment of Technical Skill (OSATS) global rating scale was used to assess technical skills. The incidence of errors and of injuries (events) were the main outcome measures, and were used to calculate the reliability, and construct and concurrent validity of the instrument.

Results

Two observers analysed 25 procedures. Inter-rater reliability was high regarding total number of errors (intraclass correlation coefficient (ICC) 0·90) and events (ICC 0·85). The median (interquartile range) error rate was 35 (26–44) and the event rate 3 (2–3) per procedure. Error frequencies and OSATS scores correlated significantly in all operative steps (rs = − 0·75 to −0·40, P = <0·001–0·046). Surgeons demonstrating high OSATS scores had lower median (i.q.r.) error rates than surgeons with low scores in three of four steps: measuring bowel (4 (2–7) versus 10 (9–11); P = 0·004), jejunojejunostomy formation (5 (2–6) versus 10 (9–11); P = 0·001) and pouch formation (4 (3–6) versus 9 (5–12); P = 0·004).

Conclusion

The proposed error rating tool allows an objective and reliable assessment of operative performance in laparoscopic gastric bypass procedures.

Depicting adverse events in cardiac theatre: the preliminary conception of the RECORD model

Human error is a byproduct of the human activity and may results in random unintended events; they may have major consequences when it comes to delivery of medicine. Furthermore the causes of error in surgical practice are multifaceted and complex. This article aims to raise awareness for safety measures in the cardiac surgical room and briefly "touch upon" the human factors that could lead to adverse outcomes. Finally, we describe a model that would enable us to depict and study adverse events in the operating theatre.

Surgical technical performance scores are predictors of late mortality and unplanned reinterventions in infants after cardiac surgery

OBJECTIVE

We have previously shown that surgical Technical Performance Scores (TPS) are important predictors of early postoperative morbidity across a wide spectrum of procedures and that intraoperative recognition and intervention of residual defects resulted in improved outcomes. We hypothesized that these scores would also be important predictors of midterm outcomes.

METHODS

Neonates and infants aged younger 6 months were prospectively followed from the index surgery for a minimum of 1 year. The TPS were calculated using previously published criteria, including intraoperative course, predischarge echocardiograms or catheterizations, and clinical data, and graded as optimal, adequate, or inadequate. Case complexity was determined by the Risk Adjustment for Congenital Heart Surgery-1 category. The primary outcome was mortality, and the secondary outcome was the need for unplanned reinterventions. Outcomes were analyzed using nonparametric methods and a logistic regression model.

RESULTS

A total of 166 patients were included in our study, with 7 early deaths. The remaining 159 patients (Risk Adjustment for Congenital Heart Surgery-1 category 4-6, 76 [48%]; neonates, 78 [49%]) were followed for a minimum of 1 year after surgery. There were 14 late deaths or late transplantations and 55 late reinterventions. On univariate analysis, the TPS were associated with mortality (P < .001) and reintervention (P = .04). On logistic regression analysis, inadequate TPS was associated with late mortality (P < .001; odds ratio, 7.2; 95% confidence interval, 2.2-23.6), and Risk Adjustment for Congenital Heart Surgery-1 category (P = .004; odds ratio, 3.7; 1.5-8.8) at index surgery was associated with need for late unplanned reintervention.

CONCLUSIONS

Technical performance affects midterm survival after infant heart surgery. Inadequate TPS can be used to prospectively identify patients at ongoing risk of demise and the need for reintervention. An aggressive approach to diagnosing and treating residual lesions at the initial operation is warranted.

Identifying the latent failures underpinning medication administration errors: an exploratory study

OBJECTIVES

The primary aim of this article was to identify the latent failures that are perceived to underpin medication errors.

STUDY SETTING

The study was conducted within three medical wards in a hospital in the United Kingdom.

STUDY DESIGN

The study employed a cross-sectional qualitative design.

DATA COLLECTION METHODS

Interviews were conducted with 12 nurses and eight managers. Interviews were transcribed and subject to thematic content analysis. A two-step inter-rater comparison tested the reliability of the themes.

PRINCIPAL FINDINGS

Ten latent failures were identified based on the analysis of the interviews. These were ward climate, local working environment, workload, human resources, team communication, routine procedures, bed management, written policies and procedures, supervision and leadership, and training. The discussion focuses on ward climate, the most prevalent theme, which is conceptualized here as interacting with failures in the nine other organizational structures and processes.

CONCLUSIONS

This study is the first of its kind to identify the latent failures perceived to underpin medication errors in a systematic way. The findings can be used as a platform for researchers to test the impact of organization-level patient safety interventions and to design proactive error management tools and incident reporting systems in hospitals.

Technical performance scores in congenital cardiac operations: a quality assessment initiative

BACKGROUND

Technical performance in congenital cardiac operations and its association with clinical outcomes was previously examined in infants and neonates. The purpose of this study was the development and implementation of a system for measuring technical performance in the majority of congenital cardiac operations to be used as a surgeon's self-assessment tool.

METHODS

Using the methodologic framework piloted at our institution, measures of technical performance were created for more than 90% of all congenital cardiac operations. Each operation was divided into multiple subprocedures to be assessed separately. Criteria for technical scores were created using a consensus panel of senior clinicians and were based primarily on the predischarge echocardiographic findings and need for early postoperative reinterventions. This system of procedure modules was then piloted by prospectively assigning technical scores to all patients undergoing operations.

RESULTS

Thirty modules were created covering more than 90% of the cardiac operations performed. One hundred eighty-five patients were enlisted. One hundred one (54.6%) cases were scored as class 1 (highest), 46 (24.9%) cases as class 2, 22 (11.9%) cases as class 3 (lowest); 16 cases (8.6%) could not be scored. The results were further analyzed by RACHS (Risk Adjustment for Congenital Heart Surgery) categories and outcomes. Valve-procedure-specific criteria were calibrated to reflect specific echocardiographic measurements.

CONCLUSIONS

The development and implementation of a broad technical performance self-assessment system for congenital cardiac operations is possible. Based on this scoring system, the impact of a less than optimal (2 or 3) technical score depends on case risk category, with higher mortality in the higher risk group, and increased resource use for lower risk procedures.

What do surgical trainees think about patient safety culture, and is this different from their consultants?

Introduction

Little is known about the patient safety culture within surgical departments in UK hospitals. What has been done to date is to survey only permanent senior staff opinion of the safety culture in their institution. This study surveyed both consultant and trainee views on perceived patient safety and compared the results between these two groups.

Material and methods

The previously validated Team Work and Safety Climate Questionnaire was configured in Survey Monkey format and sent to all surgical trainees and consultant surgeons in the South West Strategic Health Authority. Two reminders were sent to achieve as high a return rate as possible.

Results

Two hundred and ninety-six replies were received. Forty-four percent of trainees and 30% of consultants responded to the survey. Consultants consistently rated a higher safety culture than surgical trainees. Only 2.9% of trainees believe their patient safety concerns would be acted upon by hospital management. There is notable variation in perceived patient safety culture between hospitals.

Conclusion

This study has suggested that the patient safety culture in hospitals, within a Strategic Health Authority, is variable and sub-optimal when viewed by surgical trainees and their consultants. This study also provides some evidence that the perception of patient safety in an organization varies according to clinical experience. As trainees deliver a great deal of clinical care, surveys of safety culture should include this group. As perceived patient safety culture is correlated to clinical outcomes, validated safety surveys might form part of the assessment of a hospital's performance, along with outcome and patient satisfaction.

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

OBJECTIVE

The aim of this systematic review was to develop a 'contributory factors framework' from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings.

DESIGN

A mixed-methods systematic review of the literature was conducted.

DATA SOURCES

Electronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts.

ELIGIBILITY CRITERIA

Studies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety.

RESULTS

1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base.

CONCLUSIONS

This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.

Making sense of root cause analysis investigations of surgery-related adverse events

This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.

Learning surgical communication, leadership and teamwork through simulation

BACKGROUND

In Australia and New Zealand, surgical trainees are expected to develop competencies across 9 domains. Although structured training is provided in several domains, there is little or no formal program for professionalism, communication, collaboration, and management and leadership. The Australian federal Department of Health and Aging funded a pilot course in simulation-based education to address these competencies for surgical trainees. This article describes the course and evaluation.

METHODS

Course development: Content and methods drew on best-evidence for teaching and learning these competencies from other disciplines. Course evaluation: Participants completed surveys using rating scales and free text comments to identify aspects of the course that worked well and those that needed improvement.

RESULTS

Eleven of 12 participants completed evaluation forms immediately after the course. Participants reported largely meeting learning objectives and valuing the educational methods. High levels of realism in simulations contributed to the ease with which participants immersed themselves in scenarios.

CONCLUSIONS

This study demonstrates that a course designed to teach competencies in communication, teamwork, leadership, and the encompassing professionalism to surgical trainees is feasible. Although participants valued the content and methods, they identified areas for development. Limitations of the evaluation are highlighted, and further areas for research are identified.

Morbidity of the arterial switch operation

BACKGROUND

The arterial switch operation (ASO) has become a safe, reproducible surgical procedure with low mortality in experienced centers. We examined morbidity, which remains significant, particularly for complex ASO.

METHODS

From 2003 to 2011, 101 consecutive patients underwent ASO, arbitrarily classified as "simple" (n=52) or "complex" (n=49). Morbidity was measured in selected complications and postoperative hospitalization. Three outcomes were analyzed: ventilation time, postextubation hospital length of stay, and a composite morbidity index, defined as ventilation time+postextubation hospital length of stay+occurrence of selected major complications. Complexity was measured with the comprehensive Aristotle score.

RESULTS

The operative mortality was zero. Twenty-five major complications occurred in 23 patients: 6 of 25 (12%) in simple ASO and 19 of 49 (39%) in complex ASO (p=0.002). The most frequent complication was unplanned reoperation (15 vs 6, p=0.03). No patients required permanent pacing. The complex group had a significantly higher morbidity index and longer ventilation time and postextubation hospital length of stay. In multivariate analysis, factors independently predicting higher morbidity were the comprehensive Aristotle score, arch repair, bypass time, and malaligned commissures. Myocardial infarction caused one sudden late death at 3 months. Late coronary failure was 2%. Overall survival was 99% at a mean follow-up of 49±27 months.

CONCLUSIONS

In this consecutive series without operative mortality, morbidity was significantly higher in complex ASO. The only anatomic incremental risk factors for morbidity were aortic arch repair and malaligned commissures, but not primary diagnosis, weight less than 2.5 kg, or coronary patterns.

Databases and Outcomes in Congenital Cardiac Anesthesia

Anesthesia practitioners have long been at the forefront of patient safety initiatives in the operating room and beyond. The Congenital Cardiac Anesthesia Society has partnered with the Society of Thoracic Surgeons Congenital Heart Surgery Database to develop a patient registry for patients with congenital heart defects in order to determine patient outcomes related to anesthesia in this high-risk population. A review of existing database efforts is also undertaken to determine their strengths and weaknesses.

An Evaluation of Operating Room Safety and Efficiency: Pilot Utilization of a Structured Focus Group Format and Three-Dimensional Video Mock-Up to Inform Design Decision Making

Objective:

The purpose of this investigation was to identify safety and efficiency-related design features for inclusion in operating room (OR) construction documents.

Background:

Organizations are confronted with an array of challenges when planning an OR, including inefficiencies in operations, adverse events, and a variety of innovations to choose from. Currently, techniques that can be used in design practice and to inform design decision making for implementable OR solutions are limited.

Methods:

The project team used a structured focus group format with mixed methods to solicit 19 varying surgical team members' reactions to a three-dimensional video mock-up of a proposed OR. Data from the 19 participants were analyzed using stepwise multiple regression and content analysis of open-ended responses.

Results and Discussion:

Results demonstrate that several features of the proposed OR design predict meaningful outcomes, including flexibility and satisfaction with the OR setup, adverse event prevention, team performance, and distractions and interruptions. Participants' suggested solutions include universal booms to support anesthetic and perfusion capabilities, a fixed circulating nursing workstation that faces the patient and is at the foot of the operating room table, a wall-mounted monitor across from the surgeon, and wiring to support a touch-screen control arm in OR surgical fields.

Conclusions:

Findings from structured focus groups with mixed methods lead to implementable design solutions for construction documentation. The expeditious qualities and objectivity of the format are value-adds to the design decision-making process. Future research should use various techniques such as virtual technologies and building information modeling.

[Relationship between PAO2/FIO2 and SATO2/FIO2 with mortality and duration of admission in critically ill children]

OBJECTIVES

The aim of this study is to analyse the relationships and the association between PaO(2)/FiO(2) and SatO(2)/FiO(2with) the duration of admission in Paediatric Intensive Care Units (PICU) and mortality, and to study the relationships between both ratios.

MATERIAL AND METHODS

A retrospective study was conducted on PICU patients in whom a gas analysis was performed in the first twenty-four hours of admission. Demographic, clinical and ventilation variables were collected, and the relationship between PaO(2)/FiO(2) and SatO(2)/FiO(2) with days of admission and mortality was determined. Finally, the best cut-off points of SatO(2)/FiO(2) were determined for PaO(2)/FiO(2) values greater and less than 200.

RESULTS

Of 512 patients admitted during one year, a gas analysis was performed on 358, 65% of those in arterial blood. The median duration of hospitalization was two days and there were 11 patient deaths. There was a low negative correlation between the values of PaO(2)/FiO(2) and SatO(2/)FiO(2) on admission to PICU and with duration of admission, and an inverse association with mortality (P<.01). This association was stronger for the PaO(2)/FiO(2) ratio in patients with heart disease, those undergoing invasive mechanical ventilation, and for arterial blood samples. PaO(2)/FiO(2) and SatO(2)/FiO(2) ratios were significantly correlated with each other. A cut-off of 200 for SatO(2)/FiO(2) had a sensitivity of 97.5% for classifying patients with PaO(2)/FiO(2) values lower or higher than 200.

CONCLUSIONS

PaO(2)/FiO(2) and SatO(2)/FiO(2) index are markers of severity in critically ill patients. In patients who do not have an arterial line, SatO(2)/FiO(2) index can be used for assessment of oxygenation as an indicator of severity in children in critical condition.

Intraoperative adverse events can be compensated by technical performance in neonates and infants after cardiac surgery: a prospective study

OBJECTIVE

Our objective was to define the relationship between surgical technical performance score, intraoperative adverse events, and major postoperative adverse events in complex pediatric cardiac repairs.

METHOD

Infants younger than 6 months were prospectively followed up until discharge from the hospital. Technical performance scores were graded as optimal, adequate, or inadequate based on discharge echocardiograms and need for reintervention after initial surgery. Case complexity was determined by Risk Adjustment in Congenital Heart Surgery (RACHS-1) category, and preoperative illness severity was assessed by Pediatric Risk of Mortality (PRISM) III score. Intraoperative adverse events were prospectively monitored. Outcomes were analyzed using nonparametric methods and a logistic regression model.

RESULTS

A total of 166 patients (RACHS 4-6 [49%]), neonates [50%]) were observed. Sixty-one (37%) had at least 1 intraoperative adverse event, and 47 (28.3%) had at least 1 major postoperative adverse event. There was no correlation between intraoperative adverse events and RACHS, preoperative PRISM III, technical performance score, or postoperative adverse events on multivariate analysis. For the entire cohort, better technical performance score resulted in lower postoperative adverse events, lower postoperative PRISM, and lower length of stay and ventilation time (P < .001). Patients requiring intraoperative revisions fared as well as patients without, provided the technical score was at least adequate.

CONCLUSIONS

In neonatal and infant open heart repairs, technical performance score is one of the main predictors of postoperative morbidity. Outcomes are not affected by intraoperative adverse events, including surgical revisions, provided technical performance score is at least adequate.

Identification of patient safety improvement targets in successful vascular and endovascular procedures: analysis of 251 hours of complex arterial surgery

OBJECTIVES

To investigate failures in patient safety for patients undergoing vascular and endovascular procedures to guide future quality and safety interventions.

DESIGN

Single centre prospective observational study.

METHODS

66 procedures (17 thoracoabdominal and 23 abdominal aortic aneurysms, 4 carotid and 22 limb procedures) were observed prospectively over a 9-month period (251 h operating time) by two trained observers. Event logs were recorded for each procedure. Two blinded experts identified and independently categorised failures into 22 types (using a validated category tool) and severity (5-point scale). Data are expressed as median (range). Statistical analysis was performed using Mann-Whitney U, Kruskal-Wallis and Spearman's Rank tests.

RESULTS

1145 failures were identified with good inter-assessor reliability (Cronbach's alpha 0.844). The commonest failure types related to equipment (including unavailability, configuration and other failures) (269/1145 [23.5%]) and communication (240/1145 [21.0%]). A comparatively lower number of technical and psychomotor failures were identified (103 [9.0%]). The number of failures correlated with procedure duration (rho = 0.695, p < 0.001) but not anatomical site of the procedure or pathology of the disease process. Failure rate was higher in patients undergoing combined surgical/endovascular procedures compared to open surgery (median 5.7/h [IQR 4.2-8.1] vs 3.0/h [2.5-3.5]; p < 0.001). The severity of failures was similar (1.5/5 [1-2] vs 1/5 [1-2] respectively; p = 0.095). For combined procedures, failure rates were significantly higher during the endovascular phase (9.6/h [7.5-13.7]) compared to the non-endovascular phase (3.0/h [1.0-5.0]; p < 0.001).

CONCLUSIONS

Failures in patient safety are common during complex arterial procedures. Few failures were severe, although minor failures during critical stages and accumulation of multiple minor failures may potentially be important. Failures occurred especially during the endovascular phase and were often related to equipment or communication aspects. Interventions to improve procedural safety and quality of care should primarily target these specific areas.

A retrospective analysis of anesthesiologic complications in pediatric neurosurgery

BACKGROUND AND OBJECTIVE

Different clinical and surgical factors can influence the occurrence of anesthesiologic complications in pediatric neurosurgery. Preoperative knowledge of these factors is of great importance in the application of safe anesthetics and a favorable surgical outcome. The objective was to establish the importance of clinical and surgical risk factors on the frequency of anesthesia complications in pediatric neurosurgery.

DATA AND METHOD

The research, from 1996 to 2000, involved 705 children, aged from <1 year to 15 years, who underwent surgery for elective neurosurgical pathology and severe head injuries. We analysed the influence that: age, the preoperative neurologic diagnosis, the urgency of the operation, additional disorders, the surgical position, and the duration of anesthesia had on the frequency of anesthesia complications. To test the statistical relevance and to confirm the hypothesis, the Pearson's chi-square test, Mann-Whitney U-test, and univariate and multivariate logistic regressions were used.

RESULTS

Anesthesia complications (cardiovascular, respiratory, air embolism, allergic reactions) were present in 68/705 (9.6%) patients. Their frequency was statistically greater in children for whom the surgery was >240 min, who were in the sitting position and when comorbidity was evident. Neither age nor the urgency of the operation or reoperation had any significant influence on the occurrence of anesthetic complications.

CONCLUSION

The duration of anesthesia, the sitting position of the patient, and the presence of comorbidities significantly increase the risk of anesthesia complications in pediatric neurosurgery.