[A RETROSPECTIVE ANALYSIS OF SURGICAL POSITIONING INJURY USING INCIDENT REPORTING SYSTEM].

Abstract

(Purpose) Surgical positioning injury (SPI) is a cutaneous, musculoskeletal, neurological, or vascular injury resulting from the position of the patient during surgery. We performed a retrospective study using incident reporting system to examine the incidence of SPI at our hospital. (Materials and methods) Among anesthesiology managed surgical cases, SPI cases reported in the incident reporting system between 2012 and 2017 were examined. The primary endpoint was the incidence of SPI. (Results) Of 35,400 anesthesiology managed cases, 59 (0.2%) had SPI reported in the incident reporting system. Forty-four (75%) were male patients. Median age and BMI were 60 and 23.6 years, respectively. Forty-four (75%) were not supine position. Median operative time and blood loss were 419 minutes and 220 ml, respectively. Nurses reported incident reports in 52 (88%) cases, and only 7 (12%) by physicians. Skin injuries were reported in 42 cases (71%) and neurovascular injuries in 17 cases (29%). Of the neurovascular injuries, 4 (7%) were lower extremity compartment syndrome. Three cases of the 4 received the fasciotomy. (Conclusions) The incidence of SPI reported in the incident report system was 0.2%. Four cases had compartment syndrome. This result suggested the importance of intraoperative and postoperative observation in addition to proper correct positioning.