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Goldhaber NH, Mehta S, Longhurst CA, Malachowski E, Jones M, Clary BM, Schaefer RL, McHale M, Rhodes LP, Mekeel KL, Reeves JJ. Call me Ishmael: addressing the white whale of team communication in the operating room with labelled surgical caps at an academic medical centre. BMJ Open Qual 2024; 13:e002453. [PMID: 38589054 PMCID: PMC11015231 DOI: 10.1136/bmjoq-2023-002453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 02/12/2024] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION Effective communication in the operating room (OR) is crucial. Addressing a colleague by their name is respectful, humanising, entrusting and associated with improved clinical outcomes. We aimed to enhance team communication in the perioperative environment by offering personalised surgical caps labelled with name and provider role to all OR team members at a large academic medical centre. MATERIALS AND METHODS This was a quasi-experimental, uncontrolled, before-and-after quality improvement study. A survey regarding perceptions of team communication, knowledge of names and roles, communication barriers, and culture was administered before and after cap delivery. Survey results were measured on a 5-point Likert Scale; descriptive statistics and mean scores were compared. All cause National Surgical Quality Improvement Project (NSQIP) morbidity and mortality outcomes for surgical specialties were examined. RESULTS 1420 caps were delivered across the institution. Mean survey scores increased for knowing the names and roles of providers around the OR, feeling that people know my name and feeling comfortable communicating without barriers across disciplines. The mean score for team communication around the OR is excellent was unchanged. The highest score both before and after was knowing the name of an interdisciplinary team member is important for patient care. A total of 383 and 212 providers participated in the study before and after cap delivery, respectively. Participants agreed or strongly agreed that labelled surgical caps made it easier to talk to colleagues (64.9%) while improving communication (66.0%), team culture (60.5%) and patient care (56.8%). No significant differences were noted in NSQIP outcomes. CONCLUSIONS Personalised labelled surgical caps are a simple, inexpensive tool that demonstrates promise in improving perioperative team communication. Creating highly reliable surgical teams with optimal communication channels requires a multifaceted approach with engaged leadership, empowered front-line providers and an institutional commitment to continuous process improvement.
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Affiliation(s)
| | - Shivani Mehta
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Christopher A Longhurst
- Department of Pediatrics, Department of Medicine, Division of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
| | - Elizabeth Malachowski
- Perioperative Services, University of California San Diego, La Jolla, California, USA
| | - Melissa Jones
- Perioperative Services, University of California San Diego, La Jolla, California, USA
| | - Bryan M Clary
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Robin L Schaefer
- Perioperative Services, University of California San Diego, La Jolla, California, USA
| | - Michael McHale
- Department of OBGYN, University of California San Diego, La Jolla, California, USA
| | - Lisa P Rhodes
- Perioperative Services, University of California San Diego, La Jolla, California, USA
| | - Kristin L Mekeel
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - J Jeffery Reeves
- Department of Surgery, University of California San Diego, La Jolla, California, USA
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2
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Ha J. Preventing wrong-sided blocks. Int Anesthesiol Clin 2024; 62:53-57. [PMID: 38404146 DOI: 10.1097/aia.0000000000000436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Jihye Ha
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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3
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Haleem S, Mahmoud MH, Kainth GS, Botchu R, Hassan MF, Rehousek P. A perioperative overview of a retained surgical swab in spinal surgery: Case report and prevention protocol. J Perioper Pract 2024; 34:101-105. [PMID: 37125625 DOI: 10.1177/17504589231163685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Retained wound swabs although classified as a 'never event' and well documented in many surgical specialties are uncommon in spinal surgery. The aim of this article is to highlight the perioperative circumstances of an incident of a retained surgical swab and present a prevention protocol, in an attempt to eliminate its incidence. CASE REPORT The perioperative management of a 53-year-old male undergoing spinal surgery in whom a surgical swab was retained is reported. In addition to existing safety procedures such as the World Health Organization checklist, a Retained Surgical Swab-Prevention Protocol was implemented in our hospital and is presented to eliminate the occurrence of this 'never event' occurring again. CONCLUSION Retained surgical swabs or instruments are rare in spinal surgery occurring mostly in the lumbar spine, during emergency and prolonged procedures in patients with high body mass index. Maintaining a high index of suspicion and utilising a prevention protocol will prevent further harm to the patient.
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Erkan HN, Soyer Er Ö. The Retained Surgical Items Risk Assessment Scale: Development and Psychometric Characteristics. J Surg Res 2024; 296:581-588. [PMID: 38340492 DOI: 10.1016/j.jss.2023.12.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/27/2023] [Accepted: 12/24/2023] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Retained surgical items in operating rooms (ORs) continue to contribute significantly to medical errors. The first step in addressing the problem of retained surgical items is to identify the main risk factors. Identification of risk factors can impact OR standards and reduce such errors. METHODS The research included 270 participants. The data of the study were collected with the Sociodemographic and Clinical Characteristics Form, Operating Room Count Control Form and the Retained Surgical Items Risk Assessment Scale developed. In the analysis of the data, Content Validity Index, Cronbach α, item-total score correlation, Kuder-Richardson, Kappa, exploratory and confirmatory factor analysis, and Receiver Operating Characteristic (ROC) curve analysis were performed. RESULTS The Content Validity Index of the scale was 0.92. Kappa value was 0.993. The explained variance in the exploratory factor analysis of the scale was 50.03%. After confirmatory factor analysis, two factors were obtained for the final version of the 15 items. Factors had been determined as "Count and Surgery" and "Equipment". Among the subdimensions of the scale, Cronbach's α values were between 0.742 and 0.760, and 0.722 for the entire scale. When the ROC analysis results were examined, the cut-off point was ≥8, the specificity was 93.13%, and the sensitivity was 87.50%. The area under the ROC curve was calculated as 0.938. CONCLUSIONS The scale was presented as a valid and reliable measurement tool developed to assess the Retained Surgical Items Risk in ORs. If high-risk patients are checked and necessary precautions are taken before leaving the ORs, the incidence of retained surgical items can be significantly reduced.
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Affiliation(s)
- Hamide Nur Erkan
- Surgical Nursing Department, Afyonkarahisar Health Sciences University, Graduate Education Institute, Afyonkarahisar, Turkey
| | - Özlem Soyer Er
- Assistant Professor, Surgical Nursing Department, Afyonkarahisar Health Sciences University, Faculty of Health Sciences, Afyonkarahisar, Turkey.
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Shin J, Kim NY. Importance-Performance Analysis of Patient-Safety Nursing in the Operating Room: A Cross-Sectional Study. Risk Manag Healthc Policy 2024; 17:715-725. [PMID: 38559872 PMCID: PMC10981377 DOI: 10.2147/rmhp.s450340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose This study attempted to assess the perceived importance and performance of patient-safety nursing among operating room (OR) nurses and to identify the "concentrate here" level using importance-performance analysis (IPA). The goal was to identify the educational priorities of patient-safety nursing and to use it as foundational data to develop educational programs. Methods The IPA of patient-safety nursing (infection control, patient identification, specimen management, surgical coefficient, medical equipment and supplies, high-alert medicines, and damage prevention) was surveyed online for nurses in general hospitals in Korea, and the data of 47 participants were analyzed. Differences in the importance and performance of patient-safety nursing were analyzed using Wilcoxon signed rank test, and IPA was conducted to identify areas on which improvement efforts should be focused. Results Within the six areas of OR patient-safety nursing, notable differences in importance and performance were observed in infection control and surgical count areas. The IPA revealed specific items that require "concentrate here", including handwashing, checking the cleanliness and sterility of medical equipment, and conducting 5-Rights checks before administering high-alert medications. Conclusion Regular training for OR nurses should encompass preoperative, intraoperative, and postoperative infection control, as well as appropriate surgical counts. In particular, training, monitoring, feedback, and intervention should be provided on hand hygiene, sterilization maintenance, and accurate administration of high-alert medications, which are items included in "concentrate here".
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Affiliation(s)
- Jieun Shin
- Department of Biomedical Informatics, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Nam-Yi Kim
- Department of Nursing, Konyang University, Daejeon, Republic of Korea
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6
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Gillespie BM, Harbeck E, Chaboyer W. The frequency and reasons for missed nursing care in Australian perioperative nurses: A national survey. J Clin Nurs 2024. [PMID: 38380764 DOI: 10.1111/jocn.17082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/17/2024] [Accepted: 02/11/2024] [Indexed: 02/22/2024]
Abstract
AIM To describe Australian perioperative nurses' reported frequency and reasons for missed nursing care in the operating room. DESIGN Cross-sectional online survey conducted in March-April 2022. METHODS A census of Australian perioperative nurses who were members of a national professional body were invited to complete a survey that focussed on their reported frequency of missed nursing care and the reasons for missed nursing care in the operating room using the MISSCare Survey OR. RESULTS In all, 612 perioperative nurses completed the survey. The perioperative and intraoperative nursing care tasks reported as most frequently missed included time-intensive tasks and communication with multiple surgical team members present. The most frequently reported reasons for missed care were staffing-related (e.g. staff number, skill mix, fatigue and complacency) and affected teamwork. There were no significant differences in the frequency of missed care based on perioperative nurse roles. However, there were statistically significant differences between nurse management, circulating/instrument nurses and recovery room nurses in reasons for missed care. CONCLUSIONS Much of the missed care that occurs in the operating room is related to communication practices and processes, which has implications for patient safety. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Understanding the types of nursing care tasks being missed and the reasons for this missed care in the operating room may offer nurse managers deeper insights into potential strategies to address this situation. REPORTING METHOD Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Brigid M Gillespie
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Griffith University, Goldcoast, Queensland, Australia
- School of Nursing & Midwifery, Griffith University, Goldcoast, Queensland, Australia
- Gold Coast Health Nursing and Midwifery Education and Research Unit, Gold Coast University Hospital, Goldcoast, Queensland, Australia
| | - Emma Harbeck
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Griffith University, Goldcoast, Queensland, Australia
| | - Wendy Chaboyer
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Griffith University, Goldcoast, Queensland, Australia
- School of Nursing & Midwifery, Griffith University, Goldcoast, Queensland, Australia
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Wu YC, Chang CY, Huang YT, Chen SY, Chen CH, Kao HK. Artificial Intelligence Image Recognition System for Preventing Wrong-Site Upper Limb Surgery. Diagnostics (Basel) 2023; 13:3667. [PMID: 38132251 PMCID: PMC10743305 DOI: 10.3390/diagnostics13243667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023] Open
Abstract
Our image recognition system employs a deep learning model to differentiate between the left and right upper limbs in images, allowing doctors to determine the correct surgical position. From the experimental results, it was found that the precision rate and the recall rate of the intelligent image recognition system for preventing wrong-site upper limb surgery proposed in this paper could reach 98% and 93%, respectively. The results proved that our Artificial Intelligence Image Recognition System (AIIRS) could indeed assist orthopedic surgeons in preventing the occurrence of wrong-site left and right upper limb surgery. At the same time, in future, we will apply for an IRB based on our prototype experimental results and we will conduct the second phase of human trials. The results of this research paper are of great benefit and research value to upper limb orthopedic surgery.
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Affiliation(s)
- Yi-Chao Wu
- Department of Electronic Engineering, National Yunlin University of Science and Technology, Yunlin 950359, Taiwan;
| | - Chao-Yun Chang
- Interdisciplinary Program of Green and Information Technology, National Taitung University, Taitung 950359, Taiwan; (C.-Y.C.); (Y.-T.H.); (S.-Y.C.)
| | - Yu-Tse Huang
- Interdisciplinary Program of Green and Information Technology, National Taitung University, Taitung 950359, Taiwan; (C.-Y.C.); (Y.-T.H.); (S.-Y.C.)
| | - Sung-Yuan Chen
- Interdisciplinary Program of Green and Information Technology, National Taitung University, Taitung 950359, Taiwan; (C.-Y.C.); (Y.-T.H.); (S.-Y.C.)
| | - Cheng-Hsuan Chen
- Department of Electrical Engineering, National Central University, Taoyuan 320317, Taiwan;
- Department of Electrical Engineering, Fu Jen Catholic University, New Taipei City 242062, Taiwan
| | - Hsuan-Kai Kao
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 333423, Taiwan
- Bone and Joint Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
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Trieu N, Ockerman KM, Kerekes D, Han SH, Moser P, Heithaus E, Satteson E, Spiguel LP, Momeni A, Sorice-Virk S. The Incidence of Retained Objects in Intraoperative X-rays for Missing Counts in Plastic Surgery: We Should Do Better. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5419. [PMID: 38025639 PMCID: PMC10653570 DOI: 10.1097/gox.0000000000005419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023]
Abstract
Background In the event of incorrect surgical counts, obtaining X-rays to rule out retained surgical items (RSI) is standard practice. However, these safeguards also carry risk. This study investigates the actual incidence of RSI in plastic reconstructive surgery (PRS) cases as measured on intraoperative X-rays and its associated modifiable risk factors. Methods X-rays with indication of "foreign body" in PRS procedures from 2012 to 2022 were obtained. Reports with "incorrect surgical counts" and associated perioperative records were retrospectively analyzed to determine the incidence of retained surgical items. Results Among 257 X-rays, 21.4% indicated incorrect counts during PRS operations. None were positive for RSIs. The average number of staff present was 12.01. This correlated to an average of 6.98 staff turnovers. The average case lasted 8.42 hours. X-rays prolonged the time under anesthesia by an average of 24.3 minutes. Free flap surgery had 49.1% prevalence of missing counts (lower extremity 25.5%, breast 20%, craniofacial 3.6%), followed by hand (14.5%), breast (10.9%), abdominal reconstruction (10.9%), craniofacial (9.1%), and cosmetic (5.4%). Conclusions Although X-rays for incorrect counts intend to prevent catastrophic sequela of inadvertent RSIs, our results suggest the true incidence of RSI in PRS is negligible. However, intraoperative X-rays have potentially detrimental and pervasive consequences for patients, including increased anesthesia time, radiation exposure, and higher overall cost. Addressing modifiable risk factors to minimize unnecessary intraoperative X-rays is imperative while also considering whether this modality is an effective and appropriate tool in PRS procedures with incorrect surgical counts.
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Affiliation(s)
- Nhan Trieu
- From the University of Florida College of Medicine
| | | | - David Kerekes
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Fl
| | | | - Patricia Moser
- Department of Radiology, University of Florida, Gainesville, Fl
| | - Evans Heithaus
- Department of Radiology, University of Florida, Gainesville, Fl
| | - Ellen Satteson
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Fl
| | - Lisa P. Spiguel
- Division of Surgical Oncology, Department of Surgery, University of Florida, Gainesville, Fl
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Sarah Sorice-Virk
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
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Campbell K, Gardner A, Scott DJ, Johnson J, Harvey J, Kazley A. Interprofessional staff perspectives on the adoption of or black box technology and simulations to improve patient safety: a multi-methods survey. Adv Simul (Lond) 2023; 8:24. [PMID: 37880765 PMCID: PMC10598903 DOI: 10.1186/s41077-023-00263-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/24/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION Medical errors still plague healthcare. Operating Room Black Box (ORBB) and ORBB-simulation (ORBBSIM) are innovative emerging technologies which continuously capture as well as categorize intraoperative data, team information, and audio-visual files, in effort to improve objective quality measures. ORBB and ORBBSIM have an opportunity to improve patient safety, yet a paucity of implementation literature exists. Overcoming implementation barriers is critical. This study sought to obtain rich insights while identifying facilitators and barriers to adoption of ORBB and ORBBSIM in alignment with Donabedian's model of health services and healthcare quality. Enrichment themes included translational performance improvement and real-world examples to develop sessions. METHODS Interprofessional OR staff were invited to complete two surveys assessing staff's perceptions using TeamSTEPPS's validated Teamwork Perceptions Questionnaire (T-TPQ) and open-ended questions. Descriptive statistics were calculated for quantitative variables, and inductive phenomenological content analysis was used for qualitative. RESULTS Survey 1 captured 71 responses from 334 invited (RR 21%) while survey 2 captured 47 responses from 157 (RR 29.9%). The T-TPQ score was 65.2, with Communication (70.4) the highest construct and Leadership (58.0) the lowest. Quality Improvement (QI), Patient Safety, and Objective Case Review were the most common perceived ORBB benefits. Trends suggested a reciprocal benefit of dual ORBB and ORBBSIM adoption. Trends also suggested that dual implementation can promote Psychological Safety, culture, trust, and technology comfort. The need for an implementation plan built on change management principles and a constructive culture were key findings. CONCLUSIONS Findings supported ORBB implementation themes from previous literature and deepened our understanding through the exploration of team culture. This blueprint provides a model to help organizations adopt ORBB and ORBBSIM. Outcomes can establish an empirical paradigm for future studies.
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Affiliation(s)
- Krystle Campbell
- UT Southwestern Simulation Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- Department of Healthcare Leadership and Management, College of Health Professions, Doctor of Health Administration, Medical University of South Carolina, Charleston, SC, USA.
| | - Aimee Gardner
- Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA
| | - Daniel J Scott
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jada Johnson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC, USA
| | - Jillian Harvey
- Department of Healthcare Leadership and Management, College of Health Professions, Doctor of Health Administration, Medical University of South Carolina, Charleston, SC, USA
| | - Abby Kazley
- Department of Healthcare Leadership and Management, College of Health Professions, Doctor of Health Administration, Medical University of South Carolina, Charleston, SC, USA
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Kang HS, Khoraki J, Gie J, Duval D, Haynes S, Siev M, Shah J, Kim F, Mangino M, Procter L, Autorino R, Weprin S. Multiphase preclinical assessment of a novel device to locate unintentionally retained surgical sharps: a proof-of-concept study. Patient Saf Surg 2023; 17:10. [PMID: 37101230 PMCID: PMC10131432 DOI: 10.1186/s13037-023-00359-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/04/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Retained surgical sharps (RSS) is a "never event" that is preventable but may still occur despite of correct count and negative X-ray. This study assesses the feasibility of a novel device ("Melzi Sharps Finder®" or MSF) in effective detection of RSS. METHODS The first study consisted of determination of the presence of RSS or identification of RSS in an ex-vivo model (a container with hay in a laparoscopic trainer box). The second study consisted of determining presence of RSS in an in-vivo model (laparoscopy in live adult Yorkshire pigs) with 3 groups: C-arm, C-arm with MSF and MSF. The third study used similar apparatus though with laparotomy and included 2 groups: manual search and MSF. RESULTS In the first study, the MSF group had a higher rate of identification of a needle and decreased time to locate a needle versus control (98.1% vs. 22.0%, p < 0.001; 1.64 min ± 1.12vs. 3.34 min ± 1.28, p < 0.001). It also had increased accuracy of determining the presence of a needle and decreased time to reach this decision (100% vs. 58.8%, p < 0.001; 1.69 min ± 1.43 vs. 4.89 min ± 0.63, p < 0.001). In-the second study, the accuracy of determining the presence of a needle and time to reach this decision were comparable in each group (88.9% vs. 100% vs. 84.5%, p < 0.49; 2.2 min ± 2.2 vs. 2.7 min ± 2.1vs. 2.8 min ± 1.7, p = 0.68). In the third study, MSF group had higher accuracy in determining the presence of a needle and decreased time to reach this decision than the control (97.0% vs. 46.7%, p < 0.001; 2.0 min ± 1.5 vs. 3.9 min ± 1.4; p < 0.001). Multivariable analysis showed that MSF use was independently associated with an accurate determination of the presence of a needle (OR 12.1, p < 0.001). CONCLUSIONS The use of MSF in this study's RSS models facilitated the determination of presence and localization of RSS as shown by the increased rate of identification of a needle, decreased time to identification and higher accuracy in determining the presence of a needle. This device may be used in conjunction with radiography as it gives live visual and auditory feedback for users during the search for RSS.
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Affiliation(s)
- Hae Sung Kang
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Jad Khoraki
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Jessie Gie
- Department of Urology, Stanford Health, Palo Alto, CA, USA
| | - Dielle Duval
- Department of Urology, Graves Gilbert Clinic, Bowling Green, KY, USA
| | - Susan Haynes
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Michael Siev
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Jay Shah
- Department of Urology, Stanford Health, Palo Alto, CA, USA
| | - Fernando Kim
- Department of Urology, University of Colorado, Denver, CO, USA
| | - Martin Mangino
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Levi Procter
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Riccardo Autorino
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Samuel Weprin
- New Jersey Urology, Summit Health, Cherry Hill, NJ, USA.
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Arad D, Rosenfeld A, Magnezi R. Factors contributing to preventing operating room "never events": a machine learning analysis. Patient Saf Surg 2023; 17:6. [PMID: 37004090 PMCID: PMC10067209 DOI: 10.1186/s13037-023-00356-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND A surgical "Never Event" is a preventable error occurring immediately before, during or immediately following surgery. Various factors contribute to the occurrence of major Never Events, but little is known about their quantified risk in relation to a surgery's characteristics. Our study uses machine learning to reveal and quantify risk factors with the goal of improving patient safety and quality of care. METHODS We used data from 9,234 observations on safety standards and 101 root-cause analyses from actual, major "Never Events" including wrong site surgery and retained foreign item, and three random forest supervised machine learning models to identify risk factors. Using a standard 10-cross validation technique, we evaluated the models' metrics, measuring their impact on the occurrence of the two types of Never Events through Gini impurity. RESULTS We identified 24 contributing factors in six surgical departments: two had an impact of > 900% in Urology, Orthopedics, and General Surgery; six had an impact of 0-900% in Gynecology, Urology, and Cardiology; and 17 had an impact of < 0%. Combining factors revealed 15-20 pairs with an increased probability in five departments: Gynecology, 875-1900%; Urology, 1900-2600%; Cardiology, 833-1500%; Orthopedics,1825-4225%; and General Surgery, 2720-13,600%. Five factors affected wrong site surgery's occurrence (-60.96 to 503.92%) and five affected retained foreign body (-74.65 to 151.43%): two nurses (66.26-87.92%), surgery length < 1 h (85.56-122.91%), and surgery length 1-2 h (-60.96 to 85.56%). CONCLUSIONS Using machine learning, we could quantify the risk factors' potential impact on wrong site surgeries and retained foreign items in relation to a surgery's characteristics, suggesting that safety standards should be adjusted to surgery's characteristics based on risk assessment in each operating room. . TRIAL REGISTRATION NUMBER MOH 032-2019.
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Affiliation(s)
- Dana Arad
- Department of Management, Health Management Program, Faculty of Sciences, Bar-Ilan University, Ramat Gan, Israel.
- Patient Safety Division, Ministry of Health, Ramat Gan, Israel.
| | - Ariel Rosenfeld
- Department of Information Science, Bar-Ilan University, Ramat Gan, Israel
| | - Racheli Magnezi
- Department of Management, Health Management Program, Faculty of Sciences, Bar-Ilan University, Ramat Gan, Israel
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Tan J, Ross JM, Wright D, Pimentel MPT, Urman RD. A Contemporary Analysis of Closed Claims Related to Wrong-Site Surgery. Jt Comm J Qual Patient Saf 2023; 49:265-273. [PMID: 36925434 DOI: 10.1016/j.jcjq.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Wrong-site surgeries are considered "never events" and continue to occur despite the implementation of the Universal Protocol by The Joint Commission in 2003. METHODS The authors reviewed closed claims data on wrong-site surgery between 2013 and 2020 from a medical malpractice company. The claims were classified by allegations made by claimants, the responsible services, the types of procedures, the injuries, and contributing factors. Researchers performed a descriptive analysis of the available variables and reviewed the clinical summary of each case. RESULTS Between 2013 and 2020, there were 68 wrong-site closed claims cases. The mean age of the patients was 55.7 (standard deviation 16.21) years, and 51.5% were female. The services most frequently responsible for these were Orthopedic (35.3%), Neurosurgery (22.1%), and Urology (8.8%). The most common types of procedures were spine and intervertebral disc surgery (22.1%), arthroscopy (14.7%), and surgery on muscles/tendons (11.8%). The severity of claims was higher in the inpatient setting compared to the ambulatory setting. The most common alleged injuries included the need for additional surgery (45.6%), pain (33.8%), mobility dysfunction (10.3%), worsened injury (8.8%), death (7.4%), and total loss (7.4%). The top contributing factors to wrong-site surgery were failure to follow policy/protocol (83.8%) and failure to review the medical records (41.2%). The mean closed claim value was $136,452.84, and 60.3% of cases were settled. CONCLUSION The risk of wrong-site surgeries is increased with spine surgeries, likely due to unique technical challenges. Further research is required to identify effective methods of prevention of these events.
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Culebras Diaz AM, Gordo C, Mateo R, Núñez-Córdoba JM. Associations of wrong surgery with other critical healthcare quality and patient safety challenges: a cross-sectional nationwide study of 100 general hospitals in Spain. Surg Today 2023; 53:269-273. [PMID: 36056963 DOI: 10.1007/s00595-022-02580-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/04/2022] [Indexed: 01/28/2023]
Abstract
Wrong surgery (wrong-site, wrong-procedure, or wrong-patient surgery) is among the most feared patient safety problems in hospitals. We aimed to evaluate associations between numeric assessment of risk assigned to wrong surgery with that of other healthcare quality and patient safety challenges. This nationwide study collected information from healthcare quality experts in charge of a clinical quality and/or patient safety department in general hospitals of ≥ 150 beds in Spain. Out of the 100 included hospitals, the highest strength of associations were observed with risk priority number (RPN) for hospital-acquired pressure ulcers, RPN for venous thromboembolism in hospitalized patients, RPN for incorrect patient identification, RPN for lack of informed consent for diagnostic or therapeutic procedures, RPN for catheter-related bacteremia, and RPN for adverse events and injuries due to medical devices related to use and/or design. These results are of potential interest for designing combined and coordinated strategies to improve patient safety in hospitals.
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Affiliation(s)
| | - Cristina Gordo
- Healthcare Quality Service, Clínica Universidad de Navarra, Pamplona, Spain
| | - Ricardo Mateo
- Department of Business, School of Economics and Business, University of Navarra, Pamplona, Spain
| | - Jorge M Núñez-Córdoba
- Research Support Service, Central Clinical Trials Unit, Clínica Universidad de Navarra, Pamplona, Spain.
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Takahashi K, Fukatsu T, Oki S, Iizuka Y, Otsuka Y, Sanui M, Lefor AK. Characteristics of retained foreign bodies and near-miss events in the operating room: a ten-year experience at one institution. J Anesth 2023; 37:49-55. [PMID: 36346477 DOI: 10.1007/s00540-022-03127-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE Retained foreign bodies (RFBs) are a major complication of surgical procedures. However, the efficacy of preventive measures is not well defined. This study investigates the characteristics of potential (near miss) and actual RFBs, and the contributions of routine practice for the prevention of RFB events. METHODS We conducted a retrospective review of incident reports regarding near-miss and RFB events in patients who underwent surgery under general anesthesia in our institution between October 2008 and November 2018. RESULTS Among 49,831 operations under general anesthesia, there were 106 (2.13/1000) near-miss events and 24 (0.48/1000) RFB events. Counting surgical materials and intraoperative X-rays detected the remaining items before completion of surgery in 59 (56%) and 15 (14%) cases, respectively. The operator or staff noticed the surgical materials in the remaining 32 (30%) near-miss events. RFBs included 4 sponges (17%), 4 instruments (17%), 4 needles (17%), and 12 miscellaneous items (50%). Of these, 12 (50%) RFBs were discovered on postoperative X-rays and 16 (67%) patients required operative removal. Four incidents (17%) with RFBs were attributable to ignoring count discrepancies during surgery. CONCLUSION The actual incidence of RFB events is higher than previously reported. A standardized counting protocol, communication among staff, and intra- and postoperative X-rays may contribute to the prevention and detection of RFBs.
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Affiliation(s)
- Kyosuke Takahashi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan.
| | - Takeshi Fukatsu
- Department of Anesthesia, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Sayaka Oki
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yuji Otsuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Minimizing the Risk of Wrong-site Dermatologic Surgery: The Five "I"s Process. Plast Reconstr Surg Glob Open 2023; 11:e4749. [PMID: 36776585 PMCID: PMC9911201 DOI: 10.1097/gox.0000000000004749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/15/2022] [Indexed: 02/04/2023]
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Vacheron CH, Acker A, Autran M, Fuz F, Piriou V, Friggeri A, Theissen A. Insurance Claims for Wrong-Side, Wrong-Organ, Wrong-Procedure, or Wrong-Person Surgical Errors: A Retrospective Study for 10 Years. J Patient Saf 2023; 19:e13-e17. [PMID: 36538340 PMCID: PMC9788930 DOI: 10.1097/pts.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Serious adverse events, such as wrong-side, wrong-organ, wrong-procedure, or wrong-person errors, still occur despite the implementation of preventative measures. In France, we describe the claims related to such errors based on the database from one of the main insurance companies. METHODS A retrospective analysis of claims declared between January 2007 and December 2017 to Relyens, a medical liability insurance company (Sham), was performed. Their database was queried using the following keywords: "wrong side," "wrong organ," and "wrong person." RESULTS We collected 219 claims (0.4% of the total claims). The main specialties involved were orthopedics (34% of cases), neurosurgery (14%), and dentistry (14%). The claims were related to wrong organ (44%), side (39%), identity (13%), or procedure (4%). Juridical entity involved were mainly public facility (69%), followed by private facility (19%) or private physician (10%). The mean number of annual claims made has decreased of 20% since the mandatory implementation of the checklist in 2010 (22 versus 17.5 events per year). The main risk factors identified according to the ALARM protocol were factor related to the team (87%) or to the task to accomplish (78%). A direct causal factor was involved in 20% of the files, the main one being the organization (43%) closely related to the medical file (36%). The settlement was performed by conciliation in 69% of the claim and in court in 30%. The compensation was higher during a court settlement. CONCLUSIONS Wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors are rare but fully preventable by the implementation of a safety culture.
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Affiliation(s)
- Charles-Hervé Vacheron
- From the Département d’Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon
- Comité Analyse et Maitrise de Risque de la SFAR
| | - Amélie Acker
- Département d’Anesthésie Réanimation, Hôpital Femme Mère Enfant, Hospices Civils de Lyon
| | - Melanie Autran
- Directrice du Marché des Professionnels de Santé, Sham—Relyens Groupe, Lyon, France
| | - Frederic Fuz
- Directeur Risk Management Espagne, Sham—Relyens Groupe, Barcelona, Spain
| | - Vincent Piriou
- From the Département d’Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon
| | - Arnaud Friggeri
- From the Département d’Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon
| | - Alexandre Theissen
- Comité Analyse et Maitrise de Risque de la SFAR
- Service d’Anesthésie, Clinique Saint François, Groupe Vivalto, Nice, France
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Carmack A, Valleru J, Randall K, Baka D, Angarano J, Fogel R. A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items. Jt Comm J Qual Patient Saf 2023; 49:3-13. [PMID: 36334991 DOI: 10.1016/j.jcjq.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Unintentional retention of surgical items is severe but preventable patient harm in surgical procedures. One multicenter health care organization experienced a harm event due to retained surgical items (RSIs) every eight days in 2019-2020. The research team sought to reduce the incidence of harm due to RSIs, improve near-miss reporting, and increase process reliability in operating rooms across the organization. METHODS A total of 114 health care facilities in the organization were invited to participate in a multistate, multicenter patient safety initiative to reduce patient harm caused by RSIs. A national-level workgroup comprising various disciplines proposed an evidence-based best practice bundle with five elements: surgical stop, surgical debrief, visual counter, imaging, and reporting of deviations. The workgroup ensured that extensive education and support were accessible to all the participating sites. The researchers monitored the process reliability of bundle elements and improvement milestones of all the sites, along with rates of harm related to RSIs. RESULTS Implementing the evidence-based RSI reduction bundle across 114 health care facilities resulted in a 14.3% reduction in the rate of harm caused by RSIs and a 59.1% increase in RSI near-miss reporting. The compliance to the RSI bundle reached an average of 70.5%, and 63.2% of the facilities are actively performing Plan-Do-Check-Act (PDCA) cycles to improve bundle compliance continually. CONCLUSION Implementation of an RSI bundle can be done reliably, can improve near-miss reporting, and can reduce patient harm. Variation in process reliability between centers suggests the significance of overcoming cultural and organizational barriers.
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DeWane MP, Kaafarani HMA. Retained Surgical Items: How Do We Get to Zero? Jt Comm J Qual Patient Saf 2023; 49:1-2. [PMID: 36428200 DOI: 10.1016/j.jcjq.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Husebø SE, Olden M, Pedersen M, Porthun J, Balllangrud R. Translation and Psychometric Testing of the Norwegian Version of the “Patients’ Perspectives of Surgical Safety Questionnaire”. J Perianesth Nurs 2022; 38:469-477. [DOI: 10.1016/j.jopan.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/21/2022] [Accepted: 08/28/2022] [Indexed: 12/12/2022]
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Abramson HG, Curry EJ, Mess G, Thombre R, Kempski-Leadingham KM, Mistry S, Somanathan S, Roy L, Abu-Bonsrah N, Coles G, Doloff JC, Brem H, Theodore N, Huang J, Manbachi A. Automatic detection of foreign body objects in neurosurgery using a deep learning approach on intraoperative ultrasound images: From animal models to first in-human testing. Front Surg 2022; 9:1040066. [DOI: 10.3389/fsurg.2022.1040066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/18/2022] [Indexed: 12/03/2022] Open
Abstract
Objects accidentally left behind in the brain following neurosurgical procedures may lead to life-threatening health complications and invasive reoperation. One of the most commonly retained surgical items is the cotton ball, which absorbs blood to clear the surgeon’s field of view yet in the process becomes visually indistinguishable from the brain parenchyma. However, using ultrasound imaging, the different acoustic properties of cotton and brain tissue result in two discernible materials. In this study, we created a fully automated foreign body object tracking algorithm that integrates into the clinical workflow to detect and localize retained cotton balls in the brain. This deep learning algorithm uses a custom convolutional neural network and achieves 99% accuracy, sensitivity, and specificity, and surpasses other comparable algorithms. Furthermore, the trained algorithm was implemented into web and smartphone applications with the ability to detect one cotton ball in an uploaded ultrasound image in under half of a second. This study also highlights the first use of a foreign body object detection algorithm using real in-human datasets, showing its ability to prevent accidental foreign body retention in a translational setting.
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Risk Reduction Strategy to Decrease Incidence of Retained Surgical Items. J Am Coll Surg 2022; 235:494-499. [PMID: 35972170 DOI: 10.1097/xcs.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Retained surgical items (RSIs) are rare but serious events associated with significant morbidity and costs. We assessed the effectiveness of radiofrequency (RF) detection technology and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in reducing the incidence of RSIs. STUDY DESIGN All RSIs reported to the New York Patient Occurrence Reporting and Tracking System at five large urban teaching hospitals from 2007 to 2017 were analyzed. In 2012, TeamSTEPPS training was provided to all perioperative staff at each site, and use of RF detection became required in all procedures. The incidence of events before and after the interventions were compared using odds ratios. RESULTS A total of 997,237 operative procedures were analyzed. After the interventions, the incidence of RSIs decreased from 11.66 to 5.80 events per 100,000 operations (odds ratio [OR] [95% CI] = 0.50 [0.32 to 0.78]). The frequency of RSIs involving RF-detectable items decreased from 5.21 to 1.35 events per 100,000 operations (OR [95% CI] = 0.26 [0.11 to 0.60]). The difference in RSIs involving non-RF-detectable surgical items was not statistically significant. CONCLUSIONS The incidence of RSIs was significantly lower during the time period after implementing RF detection technology and after TeamSTEPPS training, primarily driven by a decrease in retained RF-detectable items. RF detection technology may be worth pursuing for hospitals looking to decrease RSI frequency. The benefit of TeamSTEPPS training alone may not result in a reduction of RSIs.
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22
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Zhang P, Liao X, Luo J. Effect of Patient Safety Training Program of Nurses in Operating Room. J Korean Acad Nurs 2022; 52:378-390. [PMID: 36117300 DOI: 10.4040/jkan.22017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/11/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE This study developed an in-service training program for patient safety and aimed to evaluate the impact of the program on nurses in the operating room (OR). METHODS A pretest-posttest self-controlled survey was conducted on OR nurses from May 6 to June 14, 2020. An in-service training program for patient safety was developed on the basis of the knowledge-attitude-practice (KAP) theory through various teaching methods. The levels of safety attitude, cognition, and attitudes toward the adverse event reporting of nurses were compared to evaluate the effect of the program. Nurses who attended the training were surveyed one week before the training (pretest) and two weeks after the training (posttest). RESULTS A total of 84 nurses participated in the study. After the training, the scores of safety attitude, cognition, and attitudes toward adverse event reporting of nurses showed a significant increase relative to the scores before the training (p < .001). The effects of safety training on the total score and the dimensions of safety attitude, cognition, and attitudes toward nurses' adverse event reporting were above the moderate level. CONCLUSION The proposed patient safety training program based on KAP theory improves the safety attitude of OR nurses. Further studies are required to develop an interprofessional patient safety training program. In addition to strength training, hospital managers need to focus on the aspects of workflow, management system, department culture, and other means to promote safety culture.
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Affiliation(s)
- Peijia Zhang
- Department of Operating Room Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Xin Liao
- Department of Operating Room Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
| | - Jie Luo
- Department of Operating Room Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Alpendre FT, Cruz EDDA, Batista J, Maziero ECS, Brandão MB. Translation, cross-cultural adaptation and content validation of the Global Trigger Tool surgical module. Rev Bras Enferm 2022; 75:e20210859. [PMID: 35858031 DOI: 10.1590/0034-7167-2021-0859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/09/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to translate, cross-culturally adapt and validate the Global Trigger Tool surgical module content for Brazil. METHOD this is methodological research, carried out between March/2018 and February/2019, following the steps of translation, synthesis, back-translation, validation by the Delphi technique, pre-test and presentation to developers. Two translators, two back-translators, six professionals participated in the expert committee. A pre-test was carried out with a retrospective analysis of 244 medical records of adult patients. The content validity index and Cronbach's alpha were determined for data analysis. RESULTS the translation and cross-cultural adaptation allowed adjustments of items for use in Brazil. The mean Content Validity Index was 1.38, and the degree of agreement among experts was 92.4%. Cronbach's alpha was 0.83 for the 11 surgical triggers and their guidelines. CONCLUSION the module was translated, cross-culturally adapted for Brazil, with high reliability to identify surgical adverse events.
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How crises work: A model of error cause and effect in surgical practice. Int J Surg 2022; 104:106711. [PMID: 35717023 DOI: 10.1016/j.ijsu.2022.106711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Surgical crises have major consequences for patients, staff and healthcare institutions. Nevertheless, their aetiology and evolution are poorly understood outside the remit of root-cause analyses. AIMS To develop a crisis model in surgery in order to aid the reporting and management of safety critical events. METHODS A narrative review surveyed the safety literature on failure causes, mechanisms and effects in the context of surgical crises. Sources were identified using non-probability sampling, with selection and inclusion being determined by author panel consensus. The data underwent thematic analysis and reporting followed the recommendation of the SALSA framework. RESULTS Data from 133 sources derived five principal themes. Analysis suggested that surgical care processes become destabilized in a step-wise manner. This crisis chain is initiated by four categories of threat or risk: (i) the systems in which surgeons operate; (ii) surgeons' technical, cognitive and behavioural skills; (iii) surgeons' physiological and psychological state (operational condition); and (iv) professional culture. Once triggered, the crisis chain is driven by only three types of errors: Type I. Performance errors consist of failures to diagnose, plan or execute tasks; Type II. Awareness errors are failures to recognise, comprehend or extrapolate the impact of performance failures; Type III. Rescue errors represent failures to correct faulty performance. The co-occurrence of all three error types gives rise to harm, which can lead to a crisis in the absence of mitigating actions. CONCLUSION Surgical crises may be triggered by four categories of threat and driven by only three types of error. These may represent universal targets for safety interventions that create new opportunities for crisis management.
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Clark JY. EDITORIAL COMMENT. Urology 2022; 164:271-272. [PMID: 35710174 DOI: 10.1016/j.urology.2021.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Joseph Y Clark
- Department of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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Eghbali F, Bhahdoust M, Madankan A, Mosavari H, Vaseghi H, Khanafshar E. Hidden retained surgical sponge with intestinal migration: A rare case report. Int J Surg Case Rep 2022. [PMCID: PMC9178464 DOI: 10.1016/j.ijscr.2022.107274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction and importance Retained surgical items are mistakenly left items used during surgery. They are not always radiopaque and in literature there are numbers of case reports that were not found by X ray. Transmigration of the retained surgical item to the small intestine is one of the possible outcomes rarely seen in patients. Case presentation we present a case 32-year-old male with a history of open appendectomy one year ago presented to the emergency department with fever and diffuse abdominal cramps, which worsened after meals. Clinical discussion Lab tests, abdominal and pelvis sonography, x-rays and CT scan and small intestine series all were unremarkable and only after defecation of a surgical gauze with blue marker, the diagnosis was made. Conclusion In all missed items at the end of operation standard counting protocols must be considered and if we couldn't find the missed item never forget the meticulous follow ups because of a great chance of non-opaque item existence, in extremely rare cases the sponge could entered the bowels without obstruction or perforation and eventually defecated. Retained surgical items are mistakenly left items used during surgery. Transmigration of the retained surgical item to the small intestine is one of the possible outcomes rarely seen in patients. In all missed items at the end of operation standard counting protocols must be considered.
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Fosch-Villaronga E, Khanna P, Drukarch H, Custers B. The Role of Humans in Surgery Automation. Int J Soc Robot 2022. [DOI: 10.1007/s12369-022-00875-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractInnovation in healthcare promises unparalleled potential in optimizing the production, distribution, and use of the health workforce and infrastructure, allocating system resources more efficiently, and streamline care pathways and supply chains. A recent innovation contributing to this is robot-assisted surgeries (RAS). RAS causes less damage to the patient's body, less pain and discomfort, shorter hospital stays, quicker recovery times, smaller scars, and less risk of complications. However, introducing a robot in traditional surgeries is not straightforward and brings about new risks that conventional medical instruments did not pose before. For instance, since robots are sophisticated machines capable of acting autonomously, the surgical procedure's outcome is no longer limited to the surgeon but may also extend to the robot manufacturer and the hospital. This article explores the influence of automation on stakeholder responsibility in surgery robotization. To this end, we map how the role of different stakeholders in highly autonomous robotic surgeries is transforming, explore some of the challenges that robot manufacturers and hospital management will increasingly face as surgical procedures become more and more automated, and bring forward potential solutions to ascertain clarity in the role of stakeholders before, during, and after robot-enabled surgeries (i.e. a Robot Impact Assessment (ROBIA), a Robo-Terms framework inspired by the international trade system 'Incoterms', and a standardized adverse event reporting mechanism). In particular, we argue that with progressive robot autonomy, performance, oversight, and support will increasingly be shared between the human surgeon, the support staff, and the robot (and, by extent, the robot manufacturer), blurring the lines of who is responsible if something goes wrong. Understanding the exact role of humans in highly autonomous robotic surgeries is essential to map liability and bring certainty concerning the ascription of responsibility. We conclude that the full benefits the use of robotic innovations and solutions in surgery could bring to healthcare providers and receivers cannot be realized until there is more clarity on the division of responsibilities channeling robot autonomy and human performance, support, and oversight; a transformation on the education and training of medical staff, and betterment on the complex interplay between manufacturers, healthcare providers, and patients.
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Pediatric surgical errors: A systematic scoping review. J Pediatr Surg 2022; 57:616-621. [PMID: 34366133 PMCID: PMC8792106 DOI: 10.1016/j.jpedsurg.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/07/2021] [Accepted: 07/22/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Medical errors were largely concealed prior to the landmark report "To Err Is Human". The purpose of this systematic scoping review was to determine the extent pediatric surgery defines and studies errors, and to explore themes among papers focused on errors in pediatric surgery. METHODS The methodological framework used to conduct this scoping study has been outlined by Arksey and O'Malley. In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Oxford Level of Evidence was assigned to each study; only studies rated Level 3 or higher were included. RESULTS Of 3,064 initial studies, 12 were included in the final analysis: 4 cohort studies, and 8 outcome/audit studies. This data represented 5,442,000 aggregate patients and 8,893 errors. There were 6 different error definitions and 5 study methods. Common themes amongst the studies included a systems-focused approach, an increase in errors seen with increased complexity, and studies exploring the relationship between error and adverse events. CONCLUSIONS This study revealed multiple error definitions, multiple error study methods, and common themes described in the pediatric surgical literature. Opportunities exist to improve the safety of surgical care of children by reducing errors. Original Scientific Research Type of Study: Systematic Scoping Review Level of Evidence Rating: 1.
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Indja B, Chen K, Cheng E, Kennedy H, Alzahrani N, Morris D. Retained surgical drain fragments: a systematic review and case report. SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ben Indja
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney Camperdown NSW Australia
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital Kogarah NSW Australia
| | - Kerry Chen
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital Kogarah NSW Australia
- St George and Sutherland Clinical School, University of New South Wales Sydney NSW Australia
| | - Ernest Cheng
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital Kogarah NSW Australia
- St George and Sutherland Clinical School, University of New South Wales Sydney NSW Australia
| | - Helen Kennedy
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital Kogarah NSW Australia
| | - Nayef Alzahrani
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital Kogarah NSW Australia
- St George and Sutherland Clinical School, University of New South Wales Sydney NSW Australia
- College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU) Riyadh Saudi Arabia
| | - David Morris
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital Kogarah NSW Australia
- St George and Sutherland Clinical School, University of New South Wales Sydney NSW Australia
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Livingston EH. Improving Preoperative Timeouts for Better Surgical Fire Readiness. JAMA Surg 2022; 157:291-292. [PMID: 35138334 DOI: 10.1001/jamasurg.2021.7551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Soori M, Shadidi-Asil R, Kialashaki M, Zamani A, Ebrahimian M. Successful laparoscopic removal of gossypiboma: A case report. Int J Surg Case Rep 2022; 91:106799. [PMID: 35093706 PMCID: PMC8808061 DOI: 10.1016/j.ijscr.2022.106799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction and importance Gossypiboma is defined as developing an exudative inflammatory process around retained foreign bodies (RFBs). This problem may be asymptomatic or present with severe systemic or regional symptoms. Traditionally, every RFB must be removed with a surgical procedure. In the era of minimally invasive surgery, laparoscopic removal is a good choice for these problems. Case presentation A young woman was referred to us with intermittent vague abdominal pain and a history of open cholecystectomy. After initial imaging, we found a twisted string-like object in epigastrium. Considering clinical findings and imaging, the patient was taken to the operating room with a diagnosis of RFB. After an explorative laparoscopy, we found an encapsulated fibrotic mass around a surgical sponge with pus-like secretions. Conclusion After diagnosing either RFB or gossypiboma, surgical intervention is mandatory, even in asymptomatic patients. Laparoscopy can help the surgeon to remove the retained item safely. Also, decreased length of stay and postoperative pain are significant advantages of laparoscopic removal. A young woman presented to us complaining of vague abdominal pain without any specific signs and symptoms. After initial imaging, a twisted string-like radiopaque object was seen in the epigastrium. The patient was operated with the aid of laparoscopy, and the retained sponge removed successfully.
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Affiliation(s)
- Mohsen Soori
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rouzbeh Shadidi-Asil
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrnoosh Kialashaki
- Department of General Surgery, Shafa Hospital, Qazvin University of Medical Sciences, Qazvin, Iran.
| | - Amir Zamani
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Manoochehr Ebrahimian
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Khanduri A, Gupta J, Ammar H, Gupta R. Laparoscopic Removal of Retained Surgical Sponge After Caesarean Section: A Case Report. Cureus 2022; 14:e21375. [PMID: 35198287 PMCID: PMC8854234 DOI: 10.7759/cureus.21375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/29/2022] Open
Abstract
Gossypiboma or textiloma denotes the formation of a mass lesion due to the development of foreign body reactions around the retained surgical item in the body. Most of the cases are asymptomatic in the initial postoperative period. Due to the dense adhesions, most of the cases of intra-abdominal gossypiboma are treated by an open approach. Here we present a case of a 38-year-old lady with left iliac fossa pain one month after caesarean section. Contrast-enhanced computed tomography of the abdomen revealed gossypiboma. The patient was successfully treated with laparoscopic removal of the gossypiboma.
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Alpendre FT, Cruz EDDA, Batista J, Maziero ECS, Brandão MB. Tradução, adaptação transcultural e validação de conteúdo do módulo cirúrgico do Global Trigger Tool. Rev Bras Enferm 2022. [DOI: 10.1590/0034-7167-2021-0859pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: traduzir, adaptar transculturalmente e validar o conteúdo do módulo cirúrgico do Global Trigger Tool para o Brasil. Método: pesquisa metodológica, realizada entre março/2018 e fevereiro/2019, seguindo os passos de tradução, síntese, retrotradução, validação pela técnica Delphi, pré-teste e apresentação para os desenvolvedores. Participaram dois tradutores, dois retrotradutores, seis profissionais para o comitê de especialistas. Realizou-se o pré-teste com análise retrospectiva de 244 prontuários de pacientes adultos. Determinou-se o índice de validade de conteúdo e alfa de Cronbach para análise dos dados. Resultados: a tradução e a adaptação transcultural permitiram ajustes dos itens para uso no Brasil. O Índice de Validade de Conteúdo médio foi 1,38, e grau de concordância entre os especialistas, 92,4 %. O alfa de Cronbach foi 0,83 para os 11 triggers cirúrgicos e respectivas orientações. Conclusão: o módulo foi traduzido e adaptado transculturalmente para o Brasil, com alta confiabilidade para identificar eventos adversos cirúrgicos.
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Abstract
OBJECTIVE Our objective was to determine the extent surgical disciplines categorize, define, and study errors, then use this information to provide recommendations for both current practice and future study. SUMMARY BACKGROUND DATA The report "To Err is Human" brought the ubiquity of medical errors to public attention. Variability in subsequent literature suggests the true prevalence of error remains unknown. METHODS In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Only studies with Oxford Level of Evidence Level 3 or higher were included. RESULTS Of 3,064 studies, 92 met inclusion criteria: 6 randomized controlled trials, 4 systematic reviews, 24 cohort, 10 before-after, 35 outcome/audit, 5 cross sectional and 8 case-control studies. Over 15,933,430 patients and 162,113 errors were represented. There were 6 broad error categories, 13 different definitions of error, and 14 study methods. CONCLUSIONS Reported prevalence of error varied widely due to a lack of standardized categorization, definitions, and study methods. Future research should focus on immediately recognizing errors to minimize harm.
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Culp WC, Muse KW. Preventing Operating Room Fires: Impact of Surgical Drapes on Oxygen Contamination of the Operative Field. J Patient Saf 2021; 17:e1846-e1850. [PMID: 32175957 DOI: 10.1097/pts.0000000000000665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to measure underdrape oxygen pooling, surgical site oxygen contamination, and time to restoration of 21% oxygen concentration after cessation of oxygen delivery by measuring oxygen concentration under simulated clinical conditions with various drapes. METHODS In a 2-part study, oxygen permeability of four differing surgical drapes was measured (Part A) and a mannequin was used to measure underdrape oxygen pooling and surgical site oxygen contamination (Part B). In Part A, a container of high concentration oxygen was sealed with a surgical drape. Oxygen concentrations on both sides of the drape were then measured over time to quantify drape oxygen permeability. Part B included a mannequin model draped for a hypothetical surgical site with oxygen administered by face mask. Oxygen concentration was measured at both the surgical site and under the drape nearest the surgical site. RESULTS Oxygen permeability varied significantly between drapes tested. The surgical site oxygen concentration ranged from 20% to 58% (P = 0.0001). The commonly used woven 100% cotton operating room (OR) towel was highly permeable. The plastic occlusive drape created an impermeable barrier, which did not allow for any oxygen contamination but created the longest time to return to 21% oxygen concentration at the underdrape site after cessation of oxygen delivery. CONCLUSIONS Surgical drapes have varying oxygen permeability and can lead to high concentration underdrape oxygen pooling. Oxygen contamination of the surgical site varies widely based on drape material and may reach dangerously high levels, especially with the cotton OR towel. Surgical drape selection may impact OR fire risk.
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Affiliation(s)
- William C Culp
- From the Department of Anesthesiology, Baylor Scott & White Medical Center, The Texas A&M University System Health Science Center College of Medicine, Temple, TX
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Franco C, Moskovitz A, Weinstein I, Kwartin S, Wolf Y. Long Term Rigid Retained Foreign Object After Breast Augmentation: A Case Report and Literature Review. Front Surg 2021; 8:725273. [PMID: 34712692 PMCID: PMC8545888 DOI: 10.3389/fsurg.2021.725273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/09/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: Retained foreign object (RFO) is a rare iatrogenic complication. This article presents an unprecedented case of a plastic RFO post-augmentation mammoplasty. Case Presentation: We present the case of a 32-year-old woman, 8 years after breast augmentation surgery, with a 4 year history of a palpable migrating mass in the superior lateral quadrant of her right breast with fluctuating levels of pain. Imaging studies included mammography tests, sonographic examinations, a Magnetic Resonance Imaging scan, and a Computed Tomography scan, all of which did not identify any pathological findings. Exploratory surgery discovered a syringe-tip cover in the implant pocket. Conclusion: Persistent complaints and symptoms accompanied by non-specific imaging studies warrant escalation of diagnostic methods, in line with a high awareness for the possibility of an RFO. As pocket lavage is a common practice in various surgeries, this report can serve as a valuable reminder for surgical teams to account for syringe covers and other disposable items at the end of all operations.
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Affiliation(s)
- Coral Franco
- Plastic Surgery Unit, Hillel Yaffe Medical Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Anner Moskovitz
- Plastic Surgery Unit, Hillel Yaffe Medical Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Iuliana Weinstein
- Department of Radiology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Samuel Kwartin
- Plastic Surgery Unit, Hillel Yaffe Medical Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yoram Wolf
- Plastic Surgery Unit, Hillel Yaffe Medical Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.,Dr. Wolf Clinic, Private Practice, Tel Aviv, Israel
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Bathla S, Chadwick M, Nevins EJ, Seward J. Preoperative Site Marking: Are We Adhering to Good Surgical Practice? J Patient Saf 2021; 17:e503-e508. [PMID: 28661999 DOI: 10.1097/pts.0000000000000398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Wrong-site surgery is a never event and a serious, preventable patient safety incident. Within the United Kingdom, national guidance has been issued to minimize the risk of such events. The mandate includes preoperative marking of all surgical patients. This study aimed to quantify regional variation in practice within general surgery and opinions of the surgeons, to help guide the formulation and implementation of a regional general surgery preoperative marking protocol. METHODS A SurveyMonkey questionnaire was designed and distributed to 120 surgeons within the Mersey region, United Kingdom. This included all surgical trainees in Mersey (47 registrars, 56 core trainees), 15 consultants, and 2 surgical care practitioners. This sought to ascertain their routine practice and how they would choose to mark for 12 index procedures in general surgery, if mandated to do so. RESULTS A total of 72 responses (60%) were obtained to the SurveyMonkey questionnaire. Only 26 (36.1%) said that they routinely marked all of their patients preoperatively. The operating surgeon marked the patient in 69% of responses, with the remainder delegating this task. Markings were visible after draping in only 55.6% of marked cases. CONCLUSIONS Based on our findings, surgeons may not be adhering to "Good Surgical Practice"; practice is widely variable and surgeons are largely opposed and resistant to marking patients unless laterality is involved. We suggest that all surgeons need to be actively engaged in the design of local marking protocols to gain support, change practice, and reduce errors.
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Affiliation(s)
| | - Michael Chadwick
- Department of General Surgery, Whiston Hospital, Prescot, United Kingdom
| | | | - Joanna Seward
- From the Department of Breast Surgery, Countess of Chester Hospital, Chester
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Hafez AT, Omar I, Purushothaman B, Michla Y, Mahawar K. Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2021; 33:319-332. [PMID: 34486990 DOI: 10.3233/jrs-210051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Never Events (NE) are serious clinical incidents that are wholly preventable if appropriate institutional safeguards are in place and followed. They are often used as a surrogate of the quality of healthcare delivered by an institution. Most NEs are surgical and orthopaedic surgery is one of the most involved specialties. OBJECTIVE The aim of this study was to identify common NE themes associated with orthopaedics within the National Health Service (NHS) of England. METHOD We conducted an observational study analysing the annual NE data published by the NHS England from 2012 to 2020 to collate all orthopaedic surgery-related NE and construct relevant recurring themes. RESULTS We identified 460 orthopaedic NE out of a total of 3247 (14.16%) reported NE to NHS England. There were 206 Wrong implants/prostheses under 8 different themes. Wrong hip and knee prosthesis were the commonest "wrong implants" (n = 94; 45.63% and n = 91; 44.17% respectively). There were 197 "Wrong-site surgery" incidents in 22 different themes. The commonest of these was the laterality problems accounting for 64 (32.48%) incidents followed by 63 (31.97%) incidents of wrong spinal level interventions. There were 18 (9.13%) incidents of intervention on the wrong patients and 17 (8.62%) wrong incisions. Retained pieces of instruments were the commonest retained foreign body with 15 (26.13%) incidents. The next categories were retained drill parts and retained instruments with 13 (22.80%) incidents each. CONCLUSION We identified 47 different themes of NE specific to orthopaedic surgery. Awareness of these themes would help in their prevention. Site marking can be challenging in the presence of cast and on operating on the digits and spine. Addition of a Real-time intra-operative implant scan to the National Joint Registry can avoid wrong implant selection while Fiducial markers, intraoperative imaging, O-arm navigation, and second time-out could help prevent wrong level spinal surgery.
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Affiliation(s)
- Ahmed T Hafez
- Royal London Hospital, Barts Health NHS Trust, Shadwell, London, UK
| | - Islam Omar
- Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - Balaji Purushothaman
- Department of Trauma and Orthopaedic Surgery, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| | - Yusuf Michla
- Department of Trauma and Orthopaedic Surgery, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| | - Kamal Mahawar
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Trust, Sunderland, UK.,Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
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Weprin S, Crocerossa F, Meyer D, Maddra K, Valancy D, Osardu R, Kang HS, Moore RH, Carbonara U, J Kim F, Autorino R. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg 2021; 15:24. [PMID: 34253246 PMCID: PMC8276389 DOI: 10.1186/s13037-021-00297-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/13/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. METHODS Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. RESULTS Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. CONCLUSION The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
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Affiliation(s)
- Samuel Weprin
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Fabio Crocerossa
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
- Division of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Dielle Meyer
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Kaitlyn Maddra
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - David Valancy
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Reginald Osardu
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Hae Sung Kang
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Robert H Moore
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Umberto Carbonara
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
- Dept of Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Fernando J Kim
- Division of Urology Denver Health Medical Center and University of Colorado Anschutz Medical Center, Colorado, Denver, USA
| | - Riccardo Autorino
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA.
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Communication failures contributing to patient injury in anaesthesia malpractice claims☆. Br J Anaesth 2021; 127:470-478. [PMID: 34238547 DOI: 10.1016/j.bja.2021.05.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/18/2021] [Accepted: 05/27/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Communication amongst team members is critical to providing safe, effective medical care. We investigated the role of communication failures in patient injury using the Anesthesia Closed Claims Project database. METHODS Claims associated with surgical/procedural and obstetric anaesthesia and postoperative pain management for adverse events from 2004 or later were included. Communication was defined as transfer of information between two or more parties. Failure was defined as communication that was incomplete, inaccurate, absent, or not timely. We classified root causes of failures as content, audience, purpose, or occasion with inter-rater reliability assessed by kappa. Claims with communication failures contributing to injury (injury-related communication failures; n=389) were compared with claims without any communication failures (n=521) using Fisher's exact test, t-test, or Mann-Whitney U-tests. RESULTS At least one communication failure contributing to patient injury occurred in 43% (n=389) out of 910 claims (κ=0.885). Patients in claims with injury-related communication failures were similar to patients in claims without failures, except that failures were more common in outpatient settings (34% vs 26%; P=0.004). Fifty-two claims had multiple communication failures for a total of 446 injury-related failures, and 47% of failures occurred during surgery, 28% preoperatively, and 23% postoperatively. Content failures (insufficient, inaccurate, or no information transmitted) accounted for 60% of the 446 communication failures. CONCLUSIONS Communication failure contributed to patient injury in 43% of anaesthesia malpractice claims. Patient/case characteristics in claims with communication failures were similar to those without failures, except that failures were more common in outpatient settings.
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Dionigi G, Raffaelli M, Bellantone R, De Crea C, Ambrosini CE, Miccoli P, Materazzi G, Ieni A, Caruso E, Zhang D, Dralle H. Analysis and outcomes of wrong site thyroid surgery. BMC Surg 2021; 21:281. [PMID: 34088279 PMCID: PMC8176686 DOI: 10.1186/s12893-021-01247-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 05/13/2021] [Indexed: 11/26/2022] Open
Abstract
Background In thyroid surgery, wrong-site surgery (WSS) is considered a rare event and seldom reported in the literature.
Case presentation This report presents 5 WSS cases following thyroid surgery in a 20-year period. We stratified the subtypes of WSS in wrong target, wrong side, wrong procedure and wrong patient. Only planned and elective thyroid surgeries present WSS cases. The interventions were performed in low-volume hospitals, and subsequently, the patients were referred to our centres. Four cases of wrong-target procedures (thymectomies [n = 3] and lymph node excision [n = 1] performed instead of thyroidectomies) and one case of wrong-side procedure were observed in this study. Two wrong target cases resulting additionally in wrong procedure were noted. Wrong patient cases were not detected in the review. Patients experienced benign, malignant, or suspicious pathology and underwent traditional surgery (no endoscopic or robotic surgery). 40% of WSS led to legal action against the surgeon or a monetary settlement. Conclusion WSS is also observed in thyroid surgery. Considering that reports regarding the serious complications of WSS are not yet available, these complications should be discussed with the surgical community. Etiologic causes, outcomes, preventive strategies of WSS and expert opinion are presented. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01247-7.
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Affiliation(s)
- Gianlorenzo Dionigi
- Division of Endocrine and Minimally Invasive Surgery, University of Messina, Messina, Italy
| | - Marco Raffaelli
- U.O.C. Chirurgia Endocrina E Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Rocco Bellantone
- U.O.C. Chirurgia Endocrina E Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Carmela De Crea
- U.O.C. Chirurgia Endocrina E Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | | | - Paolo Miccoli
- Department of Surgery, University of Pisa, Pisa, Italy
| | | | - Antonio Ieni
- Division of Pathology, University of Messina, Messina, Italy
| | - Ettore Caruso
- Division of Endocrine and Minimally Invasive Surgery, University of Messina, Messina, Italy.
| | - Daqi Zhang
- Division of Endocrine and Minimally Invasive Surgery, University of Messina, Messina, Italy.,Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital of Jilin University, Changchun, 130000, China
| | - Henning Dralle
- Sektion Endokrine Chirurgie, Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
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Truong K, Meier K, Nikolajsen L, van Tulder MW, Sørensen JCH, Rasmussen MM. Cryoneurolysis' outcome on pain experience (COPE) in patients with low-back pain: study protocol for a single-blinded randomized controlled trial. BMC Musculoskelet Disord 2021; 22:458. [PMID: 34011351 PMCID: PMC8135178 DOI: 10.1186/s12891-021-04320-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/05/2021] [Indexed: 11/26/2022] Open
Abstract
Background Low-back pain, including facet joint pain, accounts for up to 20 % of all sick leaves in DenmarkA proposed treatment option is cryoneurolysis. This study aims to investigate the effect of cryoneurolysis in lumbar facet joint pain syndrome. Methods A single-center randomized controlled trial (RCT) is performed including 120 participants with chronic facet joint pain syndrome, referred to the Department of Neurosurgery, Aarhus University Hospital. Eligible patients receive a diagnostic anesthetic block, where a reduction of pain intensity ≥ 50 % on a numerical rating scale (NRS) is required to be enrolled. Participants are randomized into three groups to undergo either one treatment of cryoneurolysis, radiofrequency ablation or placebo. Fluoroscopy and sensory stimulation is used to identify the intended target nerve prior to administrating the above-mentioned treatments. All groups receive physiotherapy for 6 weeks, starting 4 weeks after treatment. The primary outcome is the patients’ impression of change in pain after intervention (Patient Global Impression of Change (PGIC)) at 4 weeks follow-up, prior to physiotherapy. Secondary outcomes are a reduction in low-back pain intensity (numeric rating scale) and quality of life (EQ-5D, SF-36) and level of function (Oswestry Disability Index), psychological perception of pain (Pain Catastrophizing Scale) and depression status (Major Depression Inventory). Data will be assessed at baseline (T0), randomization (T1), day one (T2), 4 weeks (T3), 3 (T4), 6 (T5) and 12 months (T6). Discussion This study will provide information on the effectiveness of cryoneurolysis vs. the effectiveness of radiofrequency ablation or placebo for patients with facet joint pain, and help to establish whether cryoneurolysis should be implemented in clinical practice for this patient population. Trial registration The trial is approved by the ethical committee of Central Jutland Denmark with registration number 1-10-72-27-19 and the Danish Data Protection Agency with registration number 666,852. The study is registered at Clinicaltrial.gov with the ID number NCT04786145.
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Affiliation(s)
- K Truong
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark. .,Center for Experimental Neuroscience (CENSE) and CENSE-spine, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - K Meier
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.,Center for Experimental Neuroscience (CENSE) and CENSE-spine, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - L Nikolajsen
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - M W van Tulder
- Department of Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark.,Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - J C H Sørensen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.,Center for Experimental Neuroscience (CENSE) and CENSE-spine, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - M M Rasmussen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.,Center for Experimental Neuroscience (CENSE) and CENSE-spine, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Jueng JJ, Desai AS, Kohli N. Photographic Confirmation of Biopsy Sites Saves Lives. Fed Pract 2021; 38:227-231. [PMID: 34177232 DOI: 10.12788/fp.0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Quality photographic documentation of lesions prior to biopsy can decrease the risk of wrong site surgery, improve patient care, and save lives.
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Affiliation(s)
- Jeremy J Jueng
- is a Medical Student and is an Assistant Professor of Dermatology at the University of Central Florida College of Medicine in Orlando. is a Resident Physician at University of Florida in Gainesville. Nita Kohli is a Physician at the Gulf Coast Veterans Health Care Center in Biloxi, Mississippi
| | - Anand S Desai
- is a Medical Student and is an Assistant Professor of Dermatology at the University of Central Florida College of Medicine in Orlando. is a Resident Physician at University of Florida in Gainesville. Nita Kohli is a Physician at the Gulf Coast Veterans Health Care Center in Biloxi, Mississippi
| | - Nita Kohli
- is a Medical Student and is an Assistant Professor of Dermatology at the University of Central Florida College of Medicine in Orlando. is a Resident Physician at University of Florida in Gainesville. Nita Kohli is a Physician at the Gulf Coast Veterans Health Care Center in Biloxi, Mississippi
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Ventura Spagnolo E, Mondello C, Roccuzzo S, Baldino G, Sapienza D, Gualniera P, Asmundo A. Fire in operating room: The adverse "never" event. Case report, mini-review and medico-legal considerations. Leg Med (Tokyo) 2021; 51:101879. [PMID: 33862320 DOI: 10.1016/j.legalmed.2021.101879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/24/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
The patient's security and safety represent a topic of great importance for public health that led several healthcare organizations in many Countries to share documents to promote risk management and preventing adverse events. Surgical Fire (SF) is an infrequent adverse event generally occurring in the operating room (OR) and consisting of a fire that occurs in, on, or around a patient undergoing a medical or surgical procedure. Here a medico-legal case involving a 65-year-old woman reporting burns to the neck due to an SF during a thyroidectomy was described. A literature review was performed using Pubmed and Scopus databases, focusing on epidemiology, causes, prevention activities associated with the SF, and the related best practices recommendations. The medico-legal analysis of the case led to admit the professional liability because the suggested time (3 min) to use the electrocautery after CHG application was not respected. The case analysis and the literature review suggest the importance of implementing National and Local procedures to promote the management of SF risk. Finally, it is necessary to highlight the role of incident reporting and root causes analysis in understanding the cause of the adverse events and thus enforce their prevention.
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Affiliation(s)
- Elvira Ventura Spagnolo
- Section Legal Medicine, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Italy.
| | - Cristina Mondello
- Section of Legal Medicine, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy.
| | - Salvatore Roccuzzo
- Section of Legal Medicine, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
| | - Gennaro Baldino
- Section Legal Medicine, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Italy
| | - Daniela Sapienza
- Section of Legal Medicine, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
| | - Patrizia Gualniera
- Section of Legal Medicine, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
| | - Alessio Asmundo
- Section of Legal Medicine, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
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Atallah S, Uddin F, Seela R, Larach SW. Wrong-Side Surgery: Why Can't We Get It Right? J Patient Saf 2021; 17:192-194. [PMID: 32910038 DOI: 10.1097/pts.0000000000000780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Strabismus surgical time-out: an illustrated whiteboard modification. J AAPOS 2021; 25:72.e1-72.e4. [PMID: 33737054 DOI: 10.1016/j.jaapos.2020.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/21/2020] [Accepted: 10/30/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Errors in strabismus surgery-including wrong eye, wrong muscle, and wrong procedure-can occur when there is confusion about the surgical plan among members of the surgical team, including surgeons, anesthesia staff, nurses, and technicians. The purpose of this study was to assess whether implementation of a strabismus-specific whiteboard combined with oral statement of the surgical plan using nonophthalmological terminology could improve communication among the team before commencement of surgery. METHODS A strabismus-specific whiteboard with labeled diagram of the eyes and extraocular muscles was designed. Patient identifiers, diagnosis, deviation, and procedure name were included. This whiteboard was completed preoperatively and referenced during time-out. The surgeons and operating room staff were trained in its use, and surveys were completed before and 6 months after implementation of the whiteboard time-out. RESULTS The pre-implementation survey was completed by 19 operating room staff members, of whom 15 completed the post-implementation survey. The strabismus specific whiteboard increased staff member understanding of procedure laterality (74% to 93%), muscle(s) to be operated (37% to 93%), and specific procedure(s) planned (37% to 87%). Surgeon surveys also showed increased confidence in staff member understanding of each parameter with whiteboard use. CONCLUSIONS A standardized time-out combined with an illustrated strabismus surgery whiteboard improves communication between team members and has the potential to reduce surgical errors.
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Yun G, Kazerooni EA, Lee EM, Shah PN, Deeb M, Agarwal PP. Retained Surgical Items at Chest Imaging. Radiographics 2021; 41:E10-E11. [PMID: 33646907 DOI: 10.1148/rg.2021200128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gabin Yun
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Ella A Kazerooni
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Elizabeth M Lee
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Palmi N Shah
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Michael Deeb
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Prachi P Agarwal
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
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Bairwa BL. Gossypiboma-an unusual cause of surgical abdomen and surgeon’s nightmare: A rare case report. Int J Surg Case Rep 2021. [DOI: https://doi.org/10.1016/j.ijscr.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Gossypiboma-an unusual cause of surgical abdomen and surgeon's nightmare: A rare case report. Int J Surg Case Rep 2021; 80:105521. [PMID: 33592419 PMCID: PMC7893440 DOI: 10.1016/j.ijscr.2021.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The term Gossypiboma is used to describe a retained surgical sponge in body after surgical procedure. It is an infrequent but serious surgical complication which is seldom reported because of the medicolegal implications. It can present within days as a surgical emergency or years after the operation. CASE PRESENTATION We report a case of 30-year-old female who presented in emergency with acute pain abdomen and severe distention of abdomen. She had history of caesarean section 15 days ago at another hospital. On clinical examination and investigation, it appeared like a surgical abdomen. Contrast enhanced computed tomography suspected an intrabdominal Gossypiboma. On exploratory laparotomy there was a lump in left side of abdominal cavity. Retained surgical sponge was removed that confirmed the diagnosis of Gossypiboma. DISCUSSION Gossypiboma is a real, serious but preventable surgical complication. It affects the patient safety, cost of treatment and may cause mortality if there is delay in diagnosis and treatment. It is commonly seen in emergency and difficult surgeries. Its clinical presentation is extremely variable. It can cause acute surgical abdomen, that needs urgent surgical intervention. CONCLUSION Meticulous counts of surgical items with careful inspection of surgical site can lessen these complications. Radio frequency chip identification verification by barcode scanner can reduce the error rate.
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Yonash R, Taylor M. Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities. PATIENT SAFETY 2020. [DOI: 10.33940/data/2020.12.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.
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