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Bhargava A, Gharde P, Tayade H, Inamdar A. A Miraculous Save: Gangrenous Bowel and Meckle's Diverticulum With Acute Superior Mesenteric Artery Thrombosis. Cureus 2024; 16:e52947. [PMID: 38406144 PMCID: PMC10893989 DOI: 10.7759/cureus.52947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
The superior mesenteric artery (SMA) is vital for parts of the small intestine and ascending colon. Thrombosis of this major artery is a severe and potentially fatal condition involving the occlusion of the arterial vascular supply, causing ischemia predisposing to gangrene. Meckel's diverticulum is a congenital outpouching in the lower part of the small intestine. The condition of gangrenous meckels diverticulum is, therefore, even more limited. This study presents a unique case of a 45-year-old male with coexisting features of SMA thrombus with acute small bowel intestinal obstruction. During the study, the patient was found to have sickle cell anemia with an AS pattern, which may have predisposed the formation of a thrombus. The patient underwent sequential management of active thrombus by thrombolysis first, followed by resection anastomosis for gangrenous bowel. With precise monitoring and therapeutic care, the patient made a remarkable recovery. The condition possesses a high mortality rate. Prompt recognition and timely intervention in this case are of utmost significance.
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Affiliation(s)
- Abhilasha Bhargava
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshal Tayade
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Akash Inamdar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Zelber-Sagi S, O'Reilly-Shah VN, Fong C, Ivancovsky-Wajcman D, Reed MJ, Bentov I. Liver Fibrosis Marker and Postoperative Mortality in Patients Without Overt Liver Disease. Anesth Analg 2022; 135:957-966. [PMID: 35417420 DOI: 10.1213/ane.0000000000006044] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) can progress to advanced fibrosis, which, in the nonsurgical population, is associated with poor hepatic and extrahepatic outcomes. Despite its high prevalence, NAFLD and related liver fibrosis may be overlooked during the preoperative evaluation, and the role of liver fibrosis as an independent risk factor for surgical-related mortality has yet to be tested. The aim of this study was to assess whether fibrosis-4 (FIB-4), which consists of age, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelets, a validated marker of liver fibrosis, is associated with postoperative mortality in the general surgical population. METHODS A historical cohort of patients undergoing general anesthesia at an academic medical center between 2014 and 2018 was analyzed. Exclusion criteria included known liver disease, acute liver disease or hepatic failure, and alcohol use disorder. FIB-4 score was categorized into 3 validated predefined categories: FIB-4 ≤1.3, ruling out advanced fibrosis; >1.3 and <2.67, inconclusive; and ≥2.67, suggesting advanced fibrosis. The primary analytic method was propensity score matching (FIB-4 was dichotomized to indicate advanced fibrosis), and a secondary analysis included a multivariable logistic regression. RESULTS Of 19,861 included subjects, 1995 (10%) had advanced fibrosis per FIB-4 criteria. Mortality occurred intraoperatively in 15 patients (0.1%), during hospitalization in 272 patients (1.4%), and within 30 days of surgery in 417 patients (2.1%). FIB-4 ≥2.67 was associated with increased intraoperative mortality (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.25-10.58), mortality during hospitalization (OR, 3.14; 95% CI, 2.37-4.16), and within 30 days from surgery (OR, 2.46; 95% CI, 1.95-3.10), after adjusting for other risk factors. FIB-4 was related to increased mortality in a dose-dependent manner for the 3 FIB-4 categories ≤1.3 (reference), >1.3 and <2.67, and ≥2.67, respectively; during hospitalization (OR, 1.89; 95% CI, 1.34-2.65 and OR, 4.70; 95% CI, 3.27-6.76) and within 30 days from surgery (OR, 1.77; 95% CI, 1.36-2.31 and OR, 3.55; 95% CI, 2.65-4.77). In a 1:1 propensity-matched sample (N = 1994 per group), the differences in mortality remained. Comparing the FIB-4 ≥2.67 versus the FIB-4 <2.67 groups, respectively, mortality during hospitalization was 5.1% vs 2.2% (OR, 2.70; 95% CI, 1.81-4.02), and 30-day mortality was 6.6% vs 3.4% (OR, 2.26; 95% CI, 1.62-3.14). CONCLUSIONS A simple liver fibrosis marker is strongly associated with perioperative mortality in a population without apparent liver disease, and may aid in future surgical risk stratification and preoperative optimization.
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Affiliation(s)
- Shira Zelber-Sagi
- From the School of Public Health, University of Haifa, Haifa, Israel
| | - Vikas N O'Reilly-Shah
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Christine Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - May J Reed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Utilisation of goals of care discussions and palliative care prior to image-guided procedures near the end of life. Clin Radiol 2022; 77:345-351. [PMID: 35177227 DOI: 10.1016/j.crad.2022.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/19/2022] [Indexed: 11/03/2022]
Abstract
AIM To characterise image-guided procedures performed near the end of life and the use of goals of care discussions (GOC) and palliative care consultation (PCC) prior to these procedures. MATERIALS AND METHODS Retrospective chart review of 3,714 consecutive inpatient procedures performed for 2,351 patients and 8,206 outpatient procedures performed for 5,225 patients within a suburban medical system. Data were collected on demographics, procedures performed, mortality, and use of GOC or PCC prior to the procedures. Procedures near the end of life were classified as emergent, elective, or palliative. Logistic regression was used to assess for demographic disparities in care. RESULTS Nine percent of inpatients died within 30 days of their procedure, 57% of which were within the same hospitalisation. Of these patients, 59% had a documented GOC and 35% had a PCC. Similarly, 7% of outpatients died within 6 months of their procedure. A minority of these patients had a documented GOC (37%) or PCC (13%). There were few statistically significant demographic disparities in this care and the associated odds ratios were small. CONCLUSION A wide array of image-guided procedures is performed near the end of life. GOC and PCC are underutilised prior to these procedures. Few demographic disparities exist in this care.
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Emond YEJJM, Calsbeek H, Peters YAS, Bloo GJA, Teerenstra S, Westert GP, Damen J, Wollersheim HC, Wolff AP. Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial. Br J Anaesth 2022; 128:562-573. [PMID: 35039174 DOI: 10.1016/j.bja.2021.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/23/2021] [Accepted: 12/15/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND National Dutch guidelines have been introduced to improve suboptimal perioperative care. A multifaceted implementation programme (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) has been developed to support hospitals in applying these guidelines. This study evaluated the effectiveness of IMPROVE on guideline adherence and the association between guideline adherence and patient safety. METHODS Nine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care. RESULTS Data were analysed for 1934 patients. The IMPROVE programme improved one stop moment: 'discharge from recovery room' (+16%; 95% confidence interval [CI], 9-23%). This stop moment was related to decreased mortality (-3%; 95% CI, -4% to -1%), fewer complications (-8%; 95% CI, -13% to -3%), and fewer unscheduled transfers to the ICU (-6%; 95% CI, -9% to -3%). IMPROVE negatively affected one other stop moment - 'discharge from the hospital' - possibly because of the limited resources of hospitals to improve all stop moments together. CONCLUSIONS Mixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics. CLINICAL TRIAL REGISTRATION NTR3568 (Dutch Trial Registry).
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Affiliation(s)
- Yvette E J J M Emond
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands; Department of Anesthesiology, Pain and Palliative Care, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands.
| | - Hiske Calsbeek
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Yvonne A S Peters
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Gerrit J A Bloo
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands; Department of Anesthesiology, Pain and Palliative Care, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Steven Teerenstra
- Department for Health Evidence, Section Biostatistics, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Gert P Westert
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Johan Damen
- Department of Anesthesiology, Pain and Palliative Care, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Hub C Wollersheim
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - André P Wolff
- Department of Anesthesiology, Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Lovi A, Gallazzi E, Galbusera F, Colombini A, Pregliasco F, Peretti G, Brayda-Bruno M. Perioperative adverse events in adult and pediatric spine surgery: A prospective cohort analysis of 364 consecutive patients. BRAIN AND SPINE 2022; 2:100858. [PMID: 36248110 PMCID: PMC9560666 DOI: 10.1016/j.bas.2021.100858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/08/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Alessio Lovi
- Spine Surgery III – Scoliosis Division, I.R.C.C.S. Istituto Ortopedico Galeazzi, Milan, Italy
| | - Enrico Gallazzi
- U.O. Ortopedia e Traumatologia per le Patologie della Colonna Vertebrale, ASST Centro Specialistico Ortopedico Traumatologico G. Pini – CTO, Milan, Italy
- Corresponding author.
| | | | | | | | | | - Marco Brayda-Bruno
- Spine Surgery III – Scoliosis Division, I.R.C.C.S. Istituto Ortopedico Galeazzi, Milan, Italy
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Turrentine FE, Schenk WG, McMurry TL, Tache-Leon CA, Jones RS. Surgical errors and the relationships of disease, risks, and adverse events. Am J Surg 2020; 220:1572-1578. [PMID: 32456774 DOI: 10.1016/j.amjsurg.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Relationships between surgical errors and adverse events have not been fully explored and were examined in this study. MATERIALS AND METHODS This retrospective cohort study reviewed records of deceased surgical patients over 12 months. Bivariate associations between predictors and errors were examined. RESULTS 84 deaths occurred following 5,209 operations. Errors in care (63%) compared to those without had significantly more adverse events, (98% vs 80% respectively, p = 0.004). Significant association occurred between error and emergency status, p = 0.016); length of stay >10 days, p = 0.011; adverse events, p = 0.005). Regression results indicated number of adverse events (OR = 1.27, 95% CI (1.08-1.49), p = 0.003) and length of stay (OR = 1.05, 95% CI (1.01-1.09), p = 0.008) were associated with surgical errors. CONCLUSIONS Examining postoperative adverse events in error cases identified opportunities for improvement. Reducing medical errors requires measuring medical errors.
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Affiliation(s)
| | | | - Timothy L McMurry
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.
| | | | - R Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
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Klaas S, Kara M, Nikki M, Rhona F, Simon PB. A Ward-Round Non-Technical Skills for Surgery (WANTSS) Taxonomy. JOURNAL OF SURGICAL EDUCATION 2020; 77:369-379. [PMID: 31591044 DOI: 10.1016/j.jsurg.2019.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/14/2019] [Accepted: 09/15/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Around half of surgical adverse events occur outside the operating room. However the majority of nontechnical skills (NTS) training programs have been developed for the intraoperative environment. Ward rounds are a crucial part of extraoperative care and to date no specific NTS training manual has been developed targeting emergency general surgical ward rounds. AIM To develop a NTS taxonomy for emergency general surgical ward rounds that can be used to improve surgical team members' NTS and improve outcomes. METHODS A literature review of existing NTS taxonomies was conducted, followed by semistructured interviews and observational data collection, to determine good and poor surgical ward-round behaviors. These behaviors were reviewed by a panel of subject matter experts and categorized into a taxonomy, using the Non-Technical Skills for Surgeons taxonomy framework as a guide. RESULTS The Ward-round Non-Technical Skills for Surgery taxonomy includes examples of good and poor ward-round-specific behaviors, grouped into elements and categories. The taxonomy can be used as both a training and teaching manual for the surgical team. CONCLUSION Ward rounds are a crucial part of extraoperative surgical care. The Ward-round Non-Technical Skills for Surgery taxonomy provides surgical teams with a manual to help them improve their ward-round NTS.
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Affiliation(s)
- Schuur Klaas
- Royal College of Surgeons Edinburgh, Edinburgh, United Kingdom.
| | - Murray Kara
- Royal College of Surgeons Edinburgh, Edinburgh, United Kingdom
| | - Maran Nikki
- Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Flin Rhona
- Robert Gordon University, Aberdeen, United Kingdom
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Staerkle RF, Hoffmann H, Köckerling F, Adolf D, Bittner R, Kirchhoff P. Does coagulopathy, anticoagulant or antithrombotic therapy matter in incisional hernia repair? Data from the Herniamed Registry. Surg Endosc 2018; 32:3881-3889. [PMID: 29492708 PMCID: PMC6096530 DOI: 10.1007/s00464-018-6127-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 02/23/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND A considerable number of patients undergoing incisional hernia repair are on anticoagulant or antiplatelet therapy or have existing coagulopathy which may put them at higher risk for postoperative bleeding complications. Data about the optimal treatment of these patients are sparse. This analysis attempts to determine the rate of postoperative bleeding complications following incisional hernia repair and the consecutive rate of reoperation among patients with coagulopathy or receiving antiplatelet and anticoagulant therapy (higher risk group) compared to patients who do not have a higher risk (normal risk group). METHODS Out of the 43,101 patients documented in the Herniamed Registry who had an incisional hernia repair, 6668 (15.5%) were on anticoagulant or antithrombotic therapy or had existing coagulopathy. The implication of that higher risk profile for onset of postoperative bleeding was investigated in multivariable analysis. Hence, other influential variables were identified. RESULTS The rate of postoperative bleeding in the higher risk group was 3.9% (n = 261) and significantly higher compared to the normal risk group at 1.6% (n = 564) (OR 2.001 [1.699; 2.356]; p < 0.001). Additionally, male gender, use of drains, larger defect size, open incisional hernia repair, lower BMI, and higher ASA score significantly increased the risk of postoperative bleeding. The rate of reoperations due to postoperative bleeding was significantly increased in the higher risk group compared to the normal risk group (2.4 vs. 1.0%; OR 1.217 [1.071; 1.382]; p = 0.003). Likewise, the postoperative general complication rate (6.04 vs. 3.66%; p < 0.001) as well as the mortality rate (0.46 vs. 0.17%; p < 0.001) were significantly higher in the higher risk group. CONCLUSIONS Patients with anticoagulant or antiplatelet therapy or existing coagulopathy who undergo incisional hernia repair have a significantly higher risk for onset of postoperative bleeding. The risk of bleeding complications and complication-related reoperations seems to be lower after laparoscopic intraperitoneal onlay mesh.
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Affiliation(s)
- Ralph F Staerkle
- Department of Surgery, Clinic for Visceral Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Henry Hoffmann
- Department of Surgery, Clinic for Visceral Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany
| | - Daniela Adolf
- StatConsult GmbH, Halberstädter Straße 40 a, 39112, Magdeburg, Germany
| | - Reinhard Bittner
- Winghofer Medicum Hernia Center, Winghofer Strasse 42, 72108, Rottenburg am Neckar, Germany
| | - Philipp Kirchhoff
- Department of Surgery, Clinic for Visceral Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
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Rezaei F, Yarmohammadian M, Molavi Taleghani Y, Sheikhbardsiri H. Research Paper: Risk Assessment of Surgical Procedures in a Referral Hospital. HEALTH IN EMERGENCIES & DISASTERS QUARTERLY 2017. [DOI: 10.29252/nrip.hdq.3.1.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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10
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Intra-Abdominal Hemorrhage Complicating Electrothermal Arterial Injury During Pelvic Surgery: A Case Report. Am J Forensic Med Pathol 2017; 38:362-366. [PMID: 29068812 DOI: 10.1097/paf.0000000000000354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Iatrogenic vascular injury is a potentially serious complication of surgical procedures. Here we report a case of delayed fatal intra-abdominal hemorrhage because of electrocautery injury of a right external iliac artery. The decedent, a 31-year-old woman, died suddenly on postoperative day 1 after a laparoscopic staging operation for an ovarian tumor. Her past medical history included a recent diagnosis of a microinvasive carcinoma in the background of a mucinous cystic neoplasm of the right ovary. Postmortem examination revealed a young woman with evidence of emergency intervention, recent laparoscopic pelvic surgery, and pale hypostasis limited to the back surfaces of the body. The internal examination confirmed the postmortem computed tomography findings of a large amount of blood in the pelvic and abdominal cavities and evidence of recent surgical intervention. The soft tissues around the aorta and major pelvic vessels showed electrocautery change and marked perivascular hemorrhage preferentially surrounding the right external iliac artery. Histological examination of the vascular bundle showed an electrocautery injury of the arterial wall: transmural necrosis, acute inflammation, and hemorrhage. In this report, we offer an approach to a postmortem examination in postoperative deaths with emphasis on deaths due to iatrogenic vascular injuries and discuss the rationale for determining the manner of death.
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Karstensen S, Bari T, Gehrchen M, Street J, Dahl B. Morbidity and mortality of complex spine surgery: a prospective cohort study in 679 patients validating the Spine AdVerse Event Severity (SAVES) system in a European population. Spine J 2016; 16:146-53. [PMID: 26456809 DOI: 10.1016/j.spinee.2015.09.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 08/20/2015] [Accepted: 09/28/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Most literature on complications in spine surgery has been retrospective or based on national databases with few variables. The Spine AdVerse Events Severity (SAVES) system has been found reliable and valid in two Canadian centers, providing precise information regarding all adverse events (AEs). PURPOSE This study aimed to determine the mortality and examine the incidence of morbidity in patients undergoing complex spinal surgery, including pediatric patients, and to validate the SAVES system in a European population. STUDY DESIGN A prospective, consecutive cohort study was conducted using the SAVES version 2010 in the period from January 1, 2013 until December 31, 2013. A retrospective analysis was performed on all patients operated from November 1, 2011 until October 31, 2012 for comparison. PATIENT SAMPLE Patients undergoing spinal surgery at a tertiary referral center comprised the patient sample. OUTCOME MEASURES Morbidity and mortality were determined according to the newest version of the SAVES system and compared with the Canadian cohort. Other outcomes were length of stay, readmission, unplanned second surgery during index admission, as well as wound infections requiring revision. METHODS All patients undergoing spinal surgery at an academic tertiary referral center in the study period were prospectively included. The newest version of SAVES system was used, and a research coordinator collected all intraoperative and perioperative data prospectively. Once a week all patients were reviewed for additional events, validation of the data, and clarification of any questions. Patients were grouped according to the type of admission (elective of emergency) and age, and subgrouped according to a major diagnostic group. The survival status was registered on January 31, 2014 to obtain 30-day survival. RESULTS A total of 679 consecutive cases were included with 100% data completion. The in-hospital mortality was 1.3% and the 30-day mortality was 2.7%; all occurring after emergency procedures. The number of intraoperative AEs was 162 (overall incidence 20%), and the number of postoperative AEs was 1,415 (overall incidence 77%). Of the patients, 2.2% had postoperative infections requiring surgical revision. CONCLUSIONS A prospective registration improves AE recognition, and our data confirm the generalizability of the SAVES system to pediatric and non-Canadian populations.
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Affiliation(s)
- Sven Karstensen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen, Denmark.
| | - Tanvir Bari
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen, Denmark
| | - John Street
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Floor 6, Blusson Spinal Cord Center, 818 West 10th Ave., Vancouver, British Columbia V5Z 1M9, Canada
| | - Benny Dahl
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen, Denmark
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Wartolowska K, Judge A, Hopewell S, Collins GS, Dean BJF, Rombach I, Brindley D, Savulescu J, Beard DJ, Carr AJ. Use of placebo controls in the evaluation of surgery: systematic review. BMJ 2014; 348:g3253. [PMID: 24850821 PMCID: PMC4029190 DOI: 10.1136/bmj.g3253] [Citation(s) in RCA: 182] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate whether placebo controls should be used in the evaluation of surgical interventions. DESIGN Systematic review. DATA SOURCES We searched Medline, Embase, and the Cochrane Controlled Trials Register from their inception to November 2013. STUDY SELECTION Randomised clinical trials comparing any surgical intervention with placebo. Surgery was defined as any procedure that both changes the anatomy and requires a skin incision or use of endoscopic techniques. DATA EXTRACTION Three reviewers (KW, BJFD, IR) independently identified the relevant trials and extracted data on study details, outcomes, and harms from included studies. RESULTS In 39 out of 53 (74%) trials there was improvement in the placebo arm and in 27 (51%) trials the effect of placebo did not differ from that of surgery. In 26 (49%) trials, surgery was superior to placebo but the magnitude of the effect of the surgical intervention over that of the placebo was generally small. Serious adverse events were reported in the placebo arm in 18 trials (34%) and in the surgical arm in 22 trials (41.5%); in four trials authors did not specify in which arm the events occurred. However, in many studies adverse events were unrelated to the intervention or associated with the severity of the condition. The existing placebo controlled trials investigated only less invasive procedures that did not involve laparotomy, thoracotomy, craniotomy, or extensive tissue dissection. CONCLUSIONS Placebo controlled trial is a powerful, feasible way of showing the efficacy of surgical procedures. The risks of adverse effects associated with the placebo are small. In half of the studies, the results provide evidence against continued use of the investigated surgical procedures. Without well designed placebo controlled trials of surgery, ineffective treatment may continue unchallenged.
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Affiliation(s)
- Karolina Wartolowska
- National Institute of Health Research Musculoskeletal Biomedical Research Unit, Oxford, UK Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Andrew Judge
- National Institute of Health Research Musculoskeletal Biomedical Research Unit, Oxford, UK Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Sally Hopewell
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Gary S Collins
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Benjamin J F Dean
- National Institute of Health Research Musculoskeletal Biomedical Research Unit, Oxford, UK Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Ines Rombach
- National Institute of Health Research Musculoskeletal Biomedical Research Unit, Oxford, UK Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - David Brindley
- National Institute of Health Research Musculoskeletal Biomedical Research Unit, Oxford, UK Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK The Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation, University of Oxford, Oxford, UK Harvard Stem Cell Institute, Holyoke Centre, Cambridge, MA, USA
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - David J Beard
- National Institute of Health Research Musculoskeletal Biomedical Research Unit, Oxford, UK Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK Surgical Intervention Trials Unit (SITU), RCS Surgical Trials Unit, Botnar Institute of Musculoskeletal Sciences, Oxford, UK
| | - Andrew J Carr
- National Institute of Health Research Musculoskeletal Biomedical Research Unit, Oxford, UK Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK Surgical Intervention Trials Unit (SITU), RCS Surgical Trials Unit, Botnar Institute of Musculoskeletal Sciences, Oxford, UK
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Motta Filho GDR, Neves da Silva LDF, Ferracini AM, Bähr GL. The WHO Surgical Safety Checklist: knowledge and use by Brazilian orthopedists. Rev Bras Ortop 2013; 48:554-562. [PMID: 31304168 PMCID: PMC6565975 DOI: 10.1016/j.rboe.2013.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/16/2013] [Indexed: 11/30/2022] Open
Abstract
Objective The research examined Brazilian orthopedists’ degree of knowledge of the World Health Organization Surgical Safety Checklist. Methods A voluntary survey was conducted among the 3231 orthopedists taking part in the 44th Brazilian Congress of Orthopedics and Traumatology in November 2012, using a questionnaire on the use of WHO Surgical Safety Checklist. A statistical analysis was done upon receipt of 502 completed questionnaires. Results Among the 502 orthopedists, 40.8% reported the experience of wrong site or wrong patient surgery and 25.6% of them indicated “miscommunication” as the main cause for the error. 35.5% of the respondents do not mark the surgical site before sending the patient to the operating room and 65.3% reported lack of knowledge of the World Health Organization (WHO) Surgical Safety Checklist, fully or partially. 72.1% of the orthopedists have never been trained to use this protocol. Discussion Medical errors are more common in the surgical environment and represent a high risk to patient safety. Orthopedic surgery is a high volume specialty with major technical complexity and therefore with increased propensity for errors. Most errors are avoidable through the use of the WHO Surgical Safety Checklist. The study showed that 65.3% of Brazilian orthopedists are unaware of this protocol, despite the efforts of WHO for its disclosure.
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Affiliation(s)
- Geraldo da Rocha Motta Filho
- Shoulder and Elbow Surgery Center, Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, RJ, Brazil.,Department of Orthopedics and Traumatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Lúcia de Fátima Neves da Silva
- Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, RJ, Brazil.,Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil.,Fundação Getúlio Vargas, Rio de Janeiro, RJ, Brazil
| | - Antônio Marcos Ferracini
- Department of Orthopedics and Traumatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Orthopedics and Traumatology Service, Hospital San Rafael, Salvador, BA, Brazil
| | - Germana Lyra Bähr
- Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, RJ, Brazil.,Audencia School of Management, Nantes, France.,Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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15
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Motta Filho GDR, Neves da Silva LDF, Ferracini AM, Bähr GL. Protocolo de Cirurgia Segura da OMS: O grau de conhecimento dos ortopedistas brasileiros. Rev Bras Ortop 2013. [DOI: 10.1016/j.rbo.2013.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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16
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Anderson O, Davis R, Hanna GB, Vincent CA. Surgical adverse events: a systematic review. Am J Surg 2013; 206:253-62. [PMID: 23642651 DOI: 10.1016/j.amjsurg.2012.11.009] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 10/25/2012] [Accepted: 11/05/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim of this systematic review is to quantify potentially preventable patient harm from the frequency, severity, and preventability of the consequences and causes of surgical adverse events to help target patient safety improvement efforts. DATA SOURCES Two authors independently reviewed articles retrieved from systematic searches of the Cochrane library, MEDLINE, Embase, PsycINFO, and Cumulative Index to Nursing & Allied Health Literature databases for inclusion and exclusion criteria, methodology, and end points. All retrospective record review studies of adverse events were included. The primary end point was the frequency of general surgery adverse events. The secondary end points were the severity and preventability of consequences and causes. CONCLUSIONS Fourteen record review studies incorporating 16,424 surgical patients were included. Adverse events occurred in 14.4% of patients (interquartile range [IQR], 12.5% to 20.1%), and potentially preventable adverse events occurred in 5.2% (IQR, 4.2% to 7.0%). The consequences of 3.6% of adverse events (IQR, 3.1% to 4.4%) were fatal, those of 10.4% (IQR, 8.5% to 12.3%) were severe, those of 34.2% (IQR, 29.2% to 39.2%) were moderate, and those of 52.5% (IQR, 49.8% to 55.3%) were minor. Errors in nonoperative management caused more frequent adverse events than errors in surgical technique.
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Affiliation(s)
- Oliver Anderson
- Clinical Safety Research Unit, Centre for Patient Safety and Service Quality, Imperial College London, London, UK.
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17
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Abstract
We summarise and highlight the safety concerns within the field of trauma and orthopaedic surgery with particular emphasis placed on current controversies and reforms within the United Kingdom National Health Service.
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Affiliation(s)
- S. S. Panesar
- University of Edinburgh, Centre for
Population Health Sciences, Teviot Place, Edinburgh
EH8 9AG, UK
| | - D. A. Shaerf
- Watford General Hospital, West Hertfordshire
Hospitals NHS Trust, Vicarage Road, Watford, Hertfordshire
WD18 0HB, UK
| | - B. S. Mann
- Stoke Mandeville Hospital, Buckinghamshire
Healthcare NHS Trust, Mandeville Road, Aylesbury
HP21 8AL, UK
| | - A. K. Malik
- Stoke Mandeville Hospital, Buckinghamshire
Healthcare NHS Trust, Mandeville Road, Aylesbury
HP21 8AL, UK
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18
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Moura MDLDO, Mendes W. Avaliação de eventos adversos cirúrgicos em hospitais do Rio de Janeiro. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2012; 15:523-35. [DOI: 10.1590/s1415-790x2012000300007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 02/05/2012] [Indexed: 11/21/2022] Open
Abstract
O estudo dos eventos adversos (EAs) cirúrgicos tem especial relevância por sua frequência, porque em parte são atribuíveis a deficiências na atenção à saúde, pelo impacto considerável sobre a saúde dos pacientes, pela repercussão econômica no gasto social e sanitário e por constituir um instrumento de avaliação da qualidade da assistência. O objetivo deste estudo é avaliar a incidência de EAs cirúrgicos e os fatores contributivos em hospitais do Rio de Janeiro. Esta pesquisa é um estudo de coorte retrospectivo que buscou realizar análise descritiva de dados secundários do Programa Computacional Eventos Adversos, desenvolvido para a coleta de dados da pesquisa de avaliação da ocorrência de EAs em três hospitais de ensino localizados no Estado do Rio de Janeiro. A incidência de pacientes que desenvolveram EAs cirúrgicos foi de 3,5% (38 de 1.103 pacientes) (IC 95% 2,4 - 4,4) e a proporção de pacientes submetidos à cirurgia entre os pacientes com EAs cirúrgicos 5,9% (38 em 643) (IC 95% 4,1 - 7,6). A proporção de EAs cirúrgicos evitáveis foi de 68,3% (28 de 41 eventos) e a proporção de pacientes com EAs cirúrgicos evitáveis 65,8% (25 de 38 pacientes). Cerca de 1 em 5 pacientes com EA cirúrgico tiveram incapacidade permanente ou morreram. Mais de 60% dos casos foram classificados como pouco ou nada complexo e de baixo risco de ocorrer um EA relacionado ao cuidado.
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19
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Clark AJ, Lamborn KR, Butowski NA, Chang SM, Prados MD, Clarke JL, McDermott MW, Parsa AT, Berger MS, Aghi MK. Neurosurgical management and prognosis of patients with glioblastoma that progresses during bevacizumab treatment. Neurosurgery 2012; 70:361-70. [PMID: 21841523 DOI: 10.1227/neu.0b013e3182314f9d] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The management and prognosis of glioblastoma patients after Stupp protocol treatment and progression during bevacizumab (BV) treatment remain undefined. OBJECTIVE We compared the morbidity and survival of patients whose glioblastomas progressed during BV treatment requiring craniotomy with those of patients not treated with BV. METHODS We retrospectively reviewed patients who underwent craniotomy for recurrent glioblastoma from 2005 to 2009. Patients operated on for progression during BV (preoperative BV) were compared with patients receiving no BV or receiving BV after surgery (postoperative BV). Patients receiving BV preoperatively were compared with those patients whose gliobastoma progressed on BV treatment but were not operated on (no surgery). RESULTS There were 23 preoperative BV patients, 135 no BV patients, 16 postoperative BV patients, and 25 no surgery patients. Patients receiving BV preoperatively had a worse postoperative overall survival rate (hazard ratio, 3.1; P < .001) and worse postoperative progression-free survival rate (hazard ratio, 3.4, P < .001) than patients not receiving BV. Patients receiving BV preoperatively had a higher perioperative morbidity rate (44%) than patients not receiving preoperative BV (21%) (P = 0.02). Survival after diagnosis was comparable between groups (86-93 weeks, P = .9), consistent with glioblastomas developing BV evasion being not intrinsically more aggressive, but possibly BV evasion conferring a uniquely poor prognosis. No surgery patients had a shorter overall survival after progression during BV treatment compared with preoperative BV patients (hazard ratio, 3.6, P < .001). CONCLUSION Patients whose glioblastomas progress while receiving BV leading to craniotomy exhibit shorter postoperative survival and more perioperative morbidity than patients not treated with BV. Although there may be benefits to surgical debulking, the decision to pursue repeat surgery in patients in whom BV treatment failed must be balanced against the increased risk of perioperative complications.
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Affiliation(s)
- Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143-0112, USA
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20
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[Adverse events in general surgery. A prospective analysis of 13,950 consecutive patients]. Cir Esp 2011; 89:599-605. [PMID: 21871615 DOI: 10.1016/j.ciresp.2011.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 06/21/2011] [Accepted: 06/24/2011] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Adverse event (AE) rates in General Surgery vary, according to different authors and recording methods, between 2% and 30%. Six years ago we designed a prospective AE recording system to change patient safety culture in our Department. We present the results of this work after a 6 year follow-up. MATERIAL AND METHOD The AE, sequelae and health care errors in a University Hospital surgery department were recorded. An analysis of each incident recorded was performed by a reviewer. The data was entered into data base for rapid access and consultation. The results were routinely presented in Departmental morbidity-mortality sessions. RESULTS A total of 13,950 patients had suffered 11,254 AE, which affected 5142 of them (36.9% of admissions). A total of 920 patients were subjected to at least one health care error (6.6% of admissions). This meant that 6.6% of our patients suffered an avoidable AE. The overall mortality at 5 years in our department was 2.72% (380 deaths). An adverse event was implicated in the death of the patient in 180 cases (1.29% of admissions). In 49 cases (0.35% of admissions), mortality could be attributed to an avoidable AE. After 6 years there tends to be an increasingly lower incidence of errors. CONCLUSIONS The exhaustive and prospective recording of AE leads to changes in patient safety culture in a Surgery Department and helps decrease the incidence of health care errors.
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21
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Panesar SS, Mirza SB, Madhok R. Patient safety in orthopedics: are we doing enough? Orthopedics 2011; 34:82-3. [PMID: 21323224 DOI: 10.3928/01477447-20101221-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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22
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Dierks MM, Huang ZS, Siracuse JJ, Tolchin S, Moorman DW. Diagnostic, surgical judgment, and systems issues leading to reoperation: mining administrative databases. Am J Surg 2010; 199:324-9; discussion 329-30. [DOI: 10.1016/j.amjsurg.2009.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Revised: 09/18/2009] [Accepted: 09/18/2009] [Indexed: 10/19/2022]
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24
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Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery. World J Surg 2009; 33:191-8. [PMID: 19082657 DOI: 10.1007/s00268-008-9848-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study was designed to determine the incidence of adverse events and errors in the care of surgical patients and to demonstrate that continuous prospective collection of data on adverse events can improve quality of care and reduce the number of errors. Retrospective studies find adverse events in approximately 5% of patients admitted. Prospective studies publish figures of approximately 30%. No studies to date have tried to use continuous collection of data on adverse events to reduce the incidence of errors. METHODS Longitudinal prospective surveillance of adverse events in patients admitted to the Surgery Service during a 22-month period. Sequelae after discharge and errors during hospital stay were evaluated by peer review. RESULTS A total of 3,807 patients were controlled: 1,177 patients presented 2,193 adverse events (30.9% of admissions); 330 adverse events due to errors were detected in 258 patients (6.9% of admissions). Thirty-four deaths were considered due to adverse events (0.89% of admissions), and in 11 cases mortality was deemed avoidable (0.29% of admissions). The incidence of adverse events remained constant during the study period, but errors decreased from 11.1% to 4.5% (P = 0.005). CONCLUSIONS This is the first attempt to determine the prevalence of errors in surgery. Introducing systematic programs for recording adverse events can reduce error rates and promote a culture of patient safety in a General Surgery Department.
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Abstract
Cataract surgery is the most common procedure performed on Medicare recipients. Many of these patients have been on anticoagulation therapy (ACT) regimens, but no consistent standard currently governs the use or cessation of ACT prior to surgery. This study evaluated the safety of continuing ACT in cataract surgery patients (of ASA III physical status) at seven centers. There was a 53% incidence of previous ACT among the 1,842 individuals sampled. During 2,241 procedures, only two patients (one on ACT) experienced abnormal surgical bleeding, noted as hyphemas. Seventeen (0.9%), nine on ACT and eight not on it, had some type of bleeding related to regional anesthesia; of these, nine had bruising and eight had subconjunctival hemorrhage. No major complications were noted in the ACT group during surgery, or at visits 1 day and 1 week postoperatively.
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Affiliation(s)
- Don R Hirschman
- Robert J. Dole Veterans Administration Hospital, Wichita, Kansas, USA.
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26
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Abstract
In the past, the detection and response to adverse clinical events were viewed as an inherent part of professionalism; and, if perceived problems were not sorted out at that level, the ultimate expression of dissatisfaction was litigation. There are now demands for the adoption of more transparent and effective processes for risk management. Reviews of surgical practice have highlighted the presence of unacceptable levels of avoidable adverse events. This is being resolved in two ways. First, attention is being directed to the extent that training and experience have on outcomes after surgery, and both appear to be important. Second, a greater appreciation of human factors engineering has promoted a greater involvement of surgeons in processes involving teamwork and non-technical skills. The community wants surgeons who are competent and health-care systems that minimize risk. In recent times attention has been focused on the turmoil associated with change; but, when events are viewed over a period of several decades, there has been considerable progress towards these ideals. Further advancement would be aided by removing the adversarial nature of malpractice systems that have failed to maintain standards.
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Affiliation(s)
- Farah Aziz
- Department of Surgery, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia
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27
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Aguiló J, Peiró S, García del Caño J, Muñoz C, Garay M, Viciano V. Experiencia en el estudio de efectos adversos en un servicio de cirugía general. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1134-282x(08)74749-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Guerlain S, Adams RB, Turrentine FB, Shin T, Guo H, Collins SR, Calland JF. Assessing team performance in the operating room: Development and use of a “black-box” recorder and other tools for the intraoperative environment. J Am Coll Surg 2005; 200:29-37. [PMID: 15631917 DOI: 10.1016/j.jamcollsurg.2004.08.029] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2004] [Revised: 07/22/2004] [Accepted: 08/11/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this research was to develop a digital system to archive the complete operative environment along with the assessment tools for analysis of this data, allowing prospective studies of operative performance, intraoperative errors, team performance, and communication. Ability to study this environment will yield new insights, allowing design of systems to avoid preventable errors that contribute to perioperative complications. STUDY DESIGN A multitrack, synchronized, digital audio-visual recording system (RATE tool) was developed to monitor intraoperative performance, including software to synchronize data and allow assignment of independent observational scores. Cases were scored for technical performance, participants' situational awareness (knowledge of critical information), and their comfort and satisfaction with the conduct of the procedure. RESULTS Laparoscopic cholecystectomy (n = 10) was studied. Technical performance of the RATE tool was excellent. The RATE tool allowed real time, multitrack data collection of all aspects of the operative environment, while permitting digital recording of the objective assessment data in a time synchronized and annotated fashion during the procedure. The mean technical performance score was 73% +/- 28% of maximum (perfect) performance. Situational awareness varied widely among team members, with the attending surgeon typically the only team member having comprehensive knowledge of critical case information. CONCLUSIONS The RATE tool allows prospective analysis of performance measures such as technical judgments, team performance, and communication patterns, offers the opportunity to conduct prospective intraoperative studies of human performance, and allows for postoperative discussion, review, and teaching. This study also suggests that gaps in situational awareness might be an underappreciated source of operative adverse events. Future uses of this system will aid teaching, failure or adverse event analysis, and intervention research.
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Affiliation(s)
- Stephanie Guerlain
- Department of Systems and Information Engineering, University of Virginia, Charlottesville, VA 22908-0709, USA
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Shively EH, Heine MJ, Schell RH, Sharpe JN, Garrison RN, Vallance SR, DeSimone KJS, Polk HC. Practicing surgeons lead in quality care, safety, and cost control. Ann Surg 2004; 239:752-60; discussion 760-2. [PMID: 15166954 PMCID: PMC1356284 DOI: 10.1097/01.sla.0000128301.67780.d7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report the experiences of 66 surgical specialists from 15 different hospitals who performed 43 CPT-based procedures more than 16,000 times. SUMMARY BACKGROUND DATA Surgeons are under increasing pressure to demonstrate patient safety data as quantitated by objective and subjective outcomes that meet or exceed the standards of benchmark institutions or databases. METHODS Data from 66 surgical specialists on 43 CPT-based procedures were accessioned over a 4-year period. The hospitals vary from a small 30-bed hospital to large teaching hospitals. All reported deaths and complications were verified from hospital and office records and compared with benchmarks. RESULTS Over a 4-year inclusive period (1999-2002), 16,028 elective operations were accessioned. There was a total 1.4% complication rate and 0.05% death rate. A system has been developed for tracking outcomes. A wide range of improvements have been identified. These include the following: 1) improved classification of indications for systemic prophylactic antibiotic use and reduction in the variety of drugs used, 2) shortened length of stay for standard procedures in different surgical specialties, 3) adherence to strict indicators for selected operative procedures, 4) less use of costly diagnostic procedures, 5) decreased use of expensive home health services, 6) decreased use of very expensive drugs, 7) identification of the unnecessary expense of disposable laparoscopic devices, 8) development of a method to compare a one-surgeon hospital with his peers, and 9) development of unique protocols for interaction of anesthesia and surgery. The system also provides a very good basis for confirmation of patient safety and improvement therein. CONCLUSIONS Since 1998, Quality Surgical Solutions, PLLC, has developed simple physician-authored protocols for delivering high-quality and cost-effective surgery that measure up to benchmark institutions. We have discovered wide areas for improvements in surgery by adherence to simple protocols, minimizing death and complications and clarifying cost issues.
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Affiliation(s)
- Eugene H Shively
- Department of Surgery, University of Louisville School of Medicine; and Quality Surgical Solutions, PLLC, Louisville, KY, USA
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