Categorising reported errors and incidents from morbidity and mortality meetings (M&Ms) in a small animal multi-specialty veterinary teaching hospital

BACKGROUND

Errors in veterinary clinical settings can lead to patient harm. Morbidity and mortality meetings (M&Ms) are forums to discuss errors and incidents that can lead or have led to adverse outcomes, potential harm or unsafe conditions, with the purpose of improving patient safety in future. Despite growing implementation of M&Ms in veterinary medicine, their effectiveness in improving future patient safety may be constrained by the need for absolute confidentiality during meetings.

OBJECTIVE

To pilot the use of a simple framework to categorise errors and incidents triggering M&Ms in a multi-specialty Australian veterinary teaching hospital.

METHODOLOGY

A retrospective analysis of deidentified M&M summaries over 5 years (2018-2023) from a small animal multi-specialty veterinary teaching hospital. Animal demographic and incident information were extracted, classified by incident type and severity of harm adapted from Wallis and colleagues (2019). Descriptive statistics were produced for error category, severity, incident type and quarter of the year they occurred in. Recommendations were analysed using codebook thematic analysis.

RESULTS

There were 68 cases in total. The most common overall errors were oversight (n = 26/25.0%), drug (n = 20/19.2%), iatrogenic (n = 17, 16.3%) and staff (n = 17, 16.3%). Most cases resulted in temporary harm (n = 36, 52.9%), though 20.6% (n = 14) resulted in death, euthanasia or permanent harm. The most frequent recommendations were 'improving communications and record keeping', improving staff training' and 'ensuring appropriate equipment is available'.

CONCLUSION

Categorisation of errors using this simple framework can facilitate sharing of information which can be used to refine practices and improve animal safety, without compromising confidentiality of M&M meetings.

Instrument shank-assisted ovariohysterectomy: a randomized clinical trial of surgical and pain alleviation efficiency of a single-person modified technique

Objectives

To evaluate a modified ovariohysterectomy (OHE) technique performed by a single person and compare it with the conventional method based on time efficiency, trauma, and postoperative pain.

Methods

In a prospective, randomized, experimental study, 18 healthy, large, deep-chested, mixed-breed intact female dogs were randomly allocated to conventional (n = 9) and instrument shank-assisted (n = 9) groups. On the basis of video recordings, the various surgical step durations were analyzed: total surgery time (TST), pedicle intervention time (PIT), suspensory release time (SRT), shanking time (ShT), clamping time (ClpT), ligating time (LigT), and closure time (CT). The Glasgow composite pain scale short-form (GCMPS-SF), university of Melbourne pain scale (UMPS), and Visual Analogue Scales (VAS) were used to measure pain. C-reactive protein (CRP) fluctuation was also investigated. These evaluations were completed before and 6, 24, 48, and 72 h postoperatively.

Results

Instrument shank-assisted OHE was less time-consuming than conventional OHE (p = 0.005), improved PIT by 30.7% (6.44 min for both pedicles, p = 0.014), and correlated strongly with TST (ρ = 0.862, p = 0.003 and ρ = 0.955, p = 0.000, respectively). The two method's surgical step durations were also TST = 47.40 ± 9.9 vs. 34.70 ± 6.7 min, PIT = 20.96 ± 5.78 vs. 14.52 ± 3.73 min, SRT = 78.97 ± 69.10 vs. ShT = 20.39 ± 8.18 s (p = 0.035), ClpT = 50.66 ± 45.04 vs. 63.55 ± 37.15 s (p = 0.662), LigT = 12.82 ± 3.37 vs. 8.02 ± 3.11 min (p = 0.005), and CT = 16.40 ± 4.5 vs. 11.60 ± 2.5 min (p = 0.013), respectively. While both techniques inflicted pain on the animals, the novel approach resulted in a reduction of pain at T6 (GCMPS-SF, p = 0.015 and VAS, p = 0.002), T24 (UMPS, p = 0.003), and T48 (GCMPS-SF, p = 0.015 and UMPS, p = 0.050). Both methods exhibited a peak in CRP level after 24 h, which subsequently returned to baseline after 48 h. However, the shank-assisted method demonstrated a significantly lower reduction in CRP level at the 48-h compared to the other group (p = 0.032).

Conclusion

Instrument shank-assisted technique permitted ovarian removal without an assistant, less damage to animals and reducing its time when compared to a conventional technique, and resulting in an alternative that causes less surgical stress and fatigue. Further research with a larger population size is required to determine the serum CRP levels as an alternative pain biomarker.

Ultrasonographic appearance of retained surgical sponges and gauzes in the acute postoperative period: a phantom and cadaveric study

Retained surgical sponges or gauzes (RSS) are an uncommon complication of exploratory laparotomy surgery and pose a clinically significant risk to the patient. The purpose of this two-part, prospective, descriptive study was to describe the previously uncharacterized ultrasonographic appearance of RSS in phantom and cadaveric models of the acute postoperative period (24-48 h). For the first part of the study, a gelatin phantom containing a woven gauze with a radiopaque marker (radiopaque gauze), a woven gauze with no marker (nonradiopaque gauze), and a laparotomy sponge with a radiopaque marker (radiopaque sponge) was evaluated with ultrasonography. For the second part of the study, a total of 23 gauzes and sponges (of the aforementioned three types) were placed within the peritoneal cavity of 20 cadavers in one of three randomized locations during an exploratory laparotomy laboratory. The cadavers were imaged with ultrasonography 17 h later and still images and video clips were reviewed. The retained surgical sponges and gauzes in the gelatin phantom displayed multiple hyperechoic layers and variable degrees of distal acoustic shadowing. In cadavers, 100% (23/23) of the retained surgical sponges and gauzes displayed a single hyperechoic layer of variable thickness and distal acoustic shadowing. In 95.6% (22/23) retained sponges and gauzes, there was a thin hypoechoic layer noted superficially to the hyperechoic layer. An improved understanding of the ultrasonographic appearance of retained sponges or gauzes in the acute postoperative period may assist in the identification of these objects.

Extraskeletal osteosarcoma associated with two different types of synthetic fibers derived from a surgical swab in a dog

A 10-year-old spayed female Japanese Shiba Inu had an intraperitoneal mass that was excised surgically. The central area of the mass was composed of osteoblast-like neoplastic cells, osteoid, macrophages, and numerous fibers. The neoplastic cells showed nuclear atypia and many mitotic figures. Therefore, the central area of the mass was diagnosed as an extraskeletal osteosarcoma. The peripheral area of the mass was granuloma tissue with numerous fibers. The neoplastic and granuloma area included two types of fibers, which were identified as rayon and polyester by their morphological and staining characteristics. These fibers were consistent with those of commercial surgical swab, suggesting that the fibers may have been derived from retained surgical swabs at the time of ovariohysterectomy. Therefore, this lesion was considered an extraskeletal osteosarcoma associated with a retained surgical swab.

The impact of a surgical checklist on surgical outcomes in an academic institution

OBJECTIVE

To determine the influence of a surgical checklist (SC) on morbidities and compliance with safety measures.

STUDY DESIGN

Before-and-after-intervention study.

SAMPLE POPULATION

Three thousand two hundred eighty-six dogs: 1375 dogs pre-SC and 1911 post-SC.

METHODS

Completion of safety measures and occurrence of morbidity and/or mortality during hospitalization and up to death or 30-days postoperatively were recorded.

RESULTS

Safety measures were more frequently completed post-SC, including oral confirmation of patient identity (467/1177 [40%] vs. 1911/1911 [100%]) and oral confirmation of surgical site (568/1175 [48%] vs. 1911/1911 [100%]). In addition, duration of anesthesia decreased from 241 to 232 min (t = 2.824; p = .005); a greater proportion of animals that were intended to receive antibiotics did so prior to incision (1142/1316 [86.8%] vs. 1656/1845 [89.8%] [χ² = 6.70, p = .01]); and fewer dogs had unplanned return to the OR (32/1065 [3.0%], vs. 21/1472 [1.4%]) (χ² = 7.52, p = .006). No difference in surgical site infection (adjusted odds ratio 1.02 [95%CI: 0.63-1.66]); morbidity, (adjusted odds ratio 1.00 [95%CI: 0.77-1.29]); or death within 30 days (adjusted odds ratio 1.15 [95%CI: 0.72-1.83]) was detected on multivariable logistic regression analysis. The checklist prevented one wrong-site surgery.

CONCLUSION

Implementation of the checklist at our institution led to a decrease in anesthesia duration, increased administration of planned perioperative antibiotics before incision, increased completion of safety measures, and decreased unexpected return to the OR.

IMPACT

Despite the lack of effect on morbidities, the use of SC is recommended to improve compliance with safety measures and potentially prevent rare catastrophic events.

Intra-thoracic gossypiboma (textiloma) in a 6-year-old cocker spaniel

This report documents the first case of gossypiboma (textiloma) identified within the thorax of a dog. CT findings, surgical removal and histopathology are described. Intra-thoracic gossypiboma has not previously been reported in dogs and is rarely reported in the human medical literature, where it is most commonly associated with previous cardiac or pulmonary surgery. This dog had previously had a thoracotomy for attempted surgical correction of a persistent right aortic arch and left ligamentum arteriosum 6 years prior to presentation. A brief review of the previous literature and recommendations for prevention of this condition are provided.