Patient Safety in Surgery最新文献

{"title":"\"One family, one patient\": a human-centered approach to safety in the operating room.","authors":"Saeid Amini Rarani","doi":"10.1186/s13037-025-00436-0","DOIUrl":"10.1186/s13037-025-00436-0","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"17"},"PeriodicalIF":2.6,"publicationDate":"2025-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12100776/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144129146","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"From error to prevention of wrong-level spine surgery: a review.","authors":"Parisa Javadnia, Hasti Gohari, Nila Salimi, Ehsan Alimohammadi","doi":"10.1186/s13037-025-00440-4","DOIUrl":"10.1186/s13037-025-00440-4","url":null,"abstract":"<p><p>Wrong-level spine surgery remains a significant concern in spine surgery, leading to devastating consequences for patients and healthcare systems alike. This comprehensive review aims to analyze the existing literature on wrong-level spine surgery in spine procedures, identifying key factors that contribute to these errors and exploring advanced strategies and technologies designed to prevent them. A systematic literature search was conducted across multiple databases, including PubMed, Scopus, EMBASE, and CINAHL. The selection criteria focused on preclinical and clinical studies that specifically addressed wrong site and wrong level surgeries in the context of spine surgery. The findings reveal a range of contributing factors to wrong-level spine surgeries, including communication failures, inadequate preoperative planning, and insufficient surgical protocols. The review emphasizes the critical role of innovative technologies-such as artificial intelligence, advanced imaging techniques, and surgical navigation systems-alongside established safety protocols like digital checklists and simulation training in enhancing surgical accuracy and preventing errors. In conclusion, integrating advanced technologies and systematic safety protocols is instrumental in reducing the incidence of wrong-level spine surgeries. This review underscores the importance of continuous education and the adoption of innovative solutions to foster a culture of safety and improve surgical outcomes. By addressing the multifaceted challenges associated with these errors, the field can work towards minimizing their occurrence and enhancing patient care.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"16"},"PeriodicalIF":2.6,"publicationDate":"2025-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12080030/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144080630","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gallbladder perforation as a rare complication of minor blunt abdominal trauma: a case report.","authors":"Haddis Birhanu W/Kiros, Ashenafi Amsalu Feleke, Kidanemariam Mulualem Alamir, Temesgen Agegnehu Abebe, Wudie Mekonen Alemu, Shimelis Seid Tegegne, Habtu Adane Aytolign","doi":"10.1186/s13037-025-00431-5","DOIUrl":"https://doi.org/10.1186/s13037-025-00431-5","url":null,"abstract":"<p><strong>Background: </strong>Blunt abdominal trauma leading to gallbladder injury is rare and presents a diagnostic challenge. Here, we present scenario of gallbladder perforation due a blow from a fist to the abdomen.</p><p><strong>Case presentation: </strong>A 30-years old male patient was admitted to University of Gondar comprehensive specialized hospital emergency department in Ethiopia due to blow from a fist on the right upper abdomen with a presumptive diagnosis of generalized peritonitis and underwent emergency laparotomy. The operative finding showed that, gallbladder was perforated at the fundus and a cholecystectomy was done. Postoperative time was uneventful and discharged on the 5th postoperative day.</p><p><strong>Conclusion: </strong>Isolated gallbladder injury from a fist fight is rare, however, should be considered in the differential diagnosis of patients presenting with abdominal pain following minor blunt abdominal trauma.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"15"},"PeriodicalIF":2.6,"publicationDate":"2025-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12057175/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144040101","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient perspectives on surgical handover quality: a mixed-methods survey.","authors":"Jessica M Ryan, Philip Tomlinson, Anastasija Simiceva, Dara O Kavanagh, Walter Eppich, Ailbhe O'Driscoll Collins, Bevin Arthurs, Catherine Timon, Luke McGarry, Clothilde Dunleavy, Sandra Stewart, Annabella Stewart-Miller, Adam Fairhurst, Simon Roe, William Murray, Deborah A McNamara","doi":"10.1186/s13037-025-00437-z","DOIUrl":"https://doi.org/10.1186/s13037-025-00437-z","url":null,"abstract":"<p><strong>Background: </strong>In-hospital handover of patient care is an essential but high-risk professional activity that often lacks transparency for patients. The purpose of this survey was to gain insight into surgical patients' perceptions of handover communications between doctors, incorporating patient and public involvement to enhance accessibility and understanding.</p><p><strong>Methods: </strong>A cross-sectional, mixed-methods survey was developed with patient and public involvement and distributed to general surgery patients in two University Teaching Hospitals between 24 October 2023 and 21 July 2024. Comparative analyses of quantitative data were performed using McNemar's test for paired nominal data and Wilcoxon rank-sum test for continuous data. Free-text responses underwent thematic analysis to validate and expand on quantitative findings. Patient and public involvement partners contributed to study design, methodology, and the final manuscript.</p><p><strong>Results: </strong>In total, 208 responses were received (52.3%). Significantly more patients reported having prior knowledge of nursing handovers (73.1%) compared to doctors' handovers (63.9%; x² = 14.53, p = 0.0002). Patient perceptions of the handover process were generally positive; although satisfaction declined significantly with weekend handovers (p < 0.05). Thematic analysis identified four themes: (1) the impact of poor inter-professional communication, (2) the importance of teamwork, (3) external factors influencing handover effectiveness, and (4) patient nonchalance about their care. The use of patient and public involvement in this study improved survey accessibility and understanding of the concept and importance of handover.</p><p><strong>Conclusions: </strong>This study shows limited prior awareness of handover between doctors among surgical patients, especially the potential hazards that can arise if performed poorly. Patient and public involvement improved accessibility and understanding of the topic; however, challenges such as adequate training for meaningful engagement remain.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"14"},"PeriodicalIF":2.6,"publicationDate":"2025-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12049061/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143990199","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predictive value of the American college of surgeons \"surgical risk calculator\" (ACS-NSQIP SRC) for plastic and reconstructive surgery: a validation study from an academic tertiary referral center in Germany.","authors":"Florian Bucher, Martynas Tamulevicius, Nadjib Dastagir, Catherine Fuentes Alvarado, Doha Obed, Khaled Dastagir, Peter M Vogt","doi":"10.1186/s13037-025-00438-y","DOIUrl":"https://doi.org/10.1186/s13037-025-00438-y","url":null,"abstract":"<p><strong>Aims: </strong>The American College of Surgeons Surgical Risk Calculator (ACS-NSQIP SRC) was designed to predict morbidity and mortality in order to help providing informed consent. This study evaluated its performance in the field of plastic and reconstructive surgery for patients undergoing body contouring and breast reconstruction procedures.</p><p><strong>Methods: </strong>A retrospective analysis of patients undergoing body contouring and breast reconstruction procedures from January 1, 2022 to November 1, 2024 was performed.</p><p><strong>Results: </strong>The ACS-NSQIP SRC showed good prediction only for severe complications in patients undergoing breast reconstruction with DIEP flap (AUC = 0.727); overall prediction and calibration for the remaining 15 subgroups was poor. The incidence of overall and general complications, as well as length of hospital stay was underestimated.</p><p><strong>Conclusions: </strong>The overall performance of the ACS-NSQIP SRC was poor, a finding that underlines the importance of individual decision-making, also considering the surgeon's expertise and patient-specific characteristics.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"13"},"PeriodicalIF":2.6,"publicationDate":"2025-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12044890/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144017668","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lytic bone lesion of the skull as a rare manifestation of hepatocellular carcinoma: a case report.","authors":"Sherif Wael, Omar Hamdy, Mohamed Yasser, Sara Elmandrawi, Mai Mostafa, Nouran Mohammed, Ahmed Elghrieb","doi":"10.1186/s13037-025-00434-2","DOIUrl":"https://doi.org/10.1186/s13037-025-00434-2","url":null,"abstract":"<p><strong>Background: </strong>Hepatocellular carcinoma (HCC) ranks among the leading causes of cancer-related deaths worldwide, with metastatic spread to bones being alarmingly frequent. However, HCC metastases to the skull are notably rare, accounting for only 0.4-1.6% of all bone metastases. Typically, metastases are found in the spine, pelvis, and ribs. The occurrence of solitary skull metastases, especially in the absence of active primary liver cancer, is extremely uncommon.</p><p><strong>Case description: </strong>We present the clinical case of a 57-year-old male patient with a documented history of hepatitis C virus infection but without prior evidence of active hepatocellular carcinoma. Over the course of several months, he developed a non-tender, progressively enlarging mass located in the occipital region of the skull. A computed tomography (CT) scan identified a lytic lesion with intracranial compression, although no midline shift was noted. Histopathological examination confirmed the lesion as metastatic HCC, further supported by immunohistochemical markers Hepatari- 1 and Cytokeratin- 19. Subsequent diagnostic procedures revealed hepatic lesions, including a positron emission tomography (PET)-CT scan. Further examination through CT imaging of the abdomen with contrast highlighted a well-defined focal lesion in hepatic segment 4a, measuring 4.3 × 4.3 cm, predominantly enhancing with HCC characteristics. The skull lesion was surgically removed en bloc, and the patient underwent adjunct radiotherapy and systemic therapy, with palliative therapy till his death in May 2024. To better understand and manage this atypical presentation, we conducted a review for the discussion of clinical manifestations, imaging findings, pathological features, and patient outcomes associated with HCC skull metastases.</p><p><strong>Conclusion: </strong>This case emphasizes the critical importance of considering hepatocellular carcinoma in the differential diagnosis of solitary skull lesions, especially in patients with risk factors for liver disease. Prompt identification of the primary malignancy remains essential for ensuring optimal management and improving patient prognosis.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"12"},"PeriodicalIF":2.6,"publicationDate":"2025-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12016127/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144034302","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Wrong-site, wrong-procedure, and retained foreign object events in out-of-hospital settings: analysis of closed medico-legal complaints in Canada (2012-2021).","authors":"Omar I Hajjaj, Joanna Zaslow, Reem El Sherif, Diane L Héroux, Richard E Mimeault, Jacqueline H Fortier, Gary E Garber","doi":"10.1186/s13037-025-00432-4","DOIUrl":"https://doi.org/10.1186/s13037-025-00432-4","url":null,"abstract":"<p><strong>Background: </strong>Surgical sentinel events (SSEs) are serious safety incidents associated with significant patient harm and medico-legal consequences for healthcare teams and institutions. SSEs include wrong-site surgeries, wrong procedures, and unintentional retention of foreign objects. SSEs occur in hospitals and out-of-hospital operating spaces (physician offices or ambulatory surgical centres). It is unclear how the resource constraints and workflow differences of an out-of-hospital setting contribute to SSEs.</p><p><strong>Methods: </strong>We conducted a retrospective review and descriptive content analysis of all out-of-hospital SSEs reported to the Canadian Medical Protective Association (CMPA) between 2012 and 2021. Medico-legal files, medical records, and peer expert opinions were analyzed to identify the contributing factors to out-of-hospital wrong-site, wrong-procedure, and retained-object SSEs.</p><p><strong>Results: </strong>A total of 276 medico-legal complaints involved a wrong-site, wrong-procedure or retained-object SSE, of which 24 (24/276; 9%) occurred out of hospital. Only twenty of these out-of-hospital complaints were included in the qualitative content analysis. We identified five main contributing factor categories to out-of-hospital SSEs. These categories included (1) incomplete preoperative verification, (2) inadequate intraoperative surgical counts, (3) insufficient review of patient medical records, (4) surgery performed without the necessary resources, and (5) administrative errors or office disorganization. Half of the complaints were assigned more than one contributing factor. The majority of out-of-hospital SSEs (19/20; 95%) resulted in an unfavourable outcome for the operating physician and most (18/20; 90%) required additional healthcare resources to resolve or mitigate the consequences of the SSE.</p><p><strong>Conclusions: </strong>Recognizing the contributing factors to an out-of-hospital SSE enables targeted improvements in facility protocols to support patient safety. Some factors identified in this dataset overlap with hospital-based contributing factors previously identified in literature (incomplete preoperative verification and inadequate surgical counts), whereas other novel factors are associated with the practice environment of an out-of-hospital setting (resource constraints, office disorganization). Addressing the identified contributing factors may mitigate the risk of SSEs in all facilities.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"11"},"PeriodicalIF":2.6,"publicationDate":"2025-04-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11987446/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144015294","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving the quality of surgical morbidity and mortality conference using a standardized reporting and assessment tool: a validation study from a large academic medical center in the United States.","authors":"Sarah M Dermody, Marc C Thorne, Robert J Morrison","doi":"10.1186/s13037-025-00433-3","DOIUrl":"10.1186/s13037-025-00433-3","url":null,"abstract":"<p><strong>Background: </strong>The purpose of this study is two-fold: (1) Improve the quality of Morbidity and Mortality conferences by developing a standardized presentation template and assessment tool; (2) Assess the intervention impact by comparing pre- and post-intervention data.</p><p><strong>Methods: </strong>A pre-post study was conducted at a tertiary care academic medical center between January 2022- January 2023. A standardized presentation template was created and a short assessment tool was developed to evaluate the quality of presentations on eight domains. We hypothesized that development of this template would significantly improve the quality of M&M conferences. Pre- and post-intervention data were compared using the Kruskal-Wallis test to evaluate for significant differences. Effect sizes for each domain were assessed by Cohen's d.</p><p><strong>Results: </strong>A total of 127 pre-intervention responses and 61 post-intervention responses were received over a six-month period. Statistically significant increases in post-intervention scores were noted in nearly all presentation domains, including clarity of case selection rationale, nature of the safety event, circumstances leading to the safety event, contributing factors, understanding of the safety event, and anticipated benefits to patient outcomes (p < 0.05). The effect sizes ranged from medium for rationale for case selection to small for the identification of corrective actions.</p><p><strong>Conclusions: </strong>The introduction of a standardized, guided template improved the quality of Morbidity and Mortality presentations, with medium effect sizes and statistically significant increases in nearly all surveyed domains. A ceiling effect in the overall assessment score was noted as presentations prior to the intervention were rated highly. Standardization of case selection and presentations can promote alignment of the Quality Improvement Morbidity and Mortality workflow with broader-scope initiatives, departmentally and institutionally.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"10"},"PeriodicalIF":2.6,"publicationDate":"2025-04-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11971917/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143789168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Postoperative infection, wrong-site surgery, and patient death after elective low-value orthopedic surgery: the epitome of preventable surgical complications.","authors":"Philip F Stahel, Navid Ziran","doi":"10.1186/s13037-025-00429-z","DOIUrl":"10.1186/s13037-025-00429-z","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"9"},"PeriodicalIF":2.6,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11931739/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143701779","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nocturnal elective coronary artery bypass grafting (CABG) surgery is not associated with increased one-year mortality.","authors":"Andreas Koköfer, Christian Dinges, Crispiana Cozowicz, Bernhard Wernly, Niklas Rodemund","doi":"10.1186/s13037-025-00430-6","DOIUrl":"10.1186/s13037-025-00430-6","url":null,"abstract":"<p><strong>Background: </strong>Elective coronary artery bypass grafting (CABG) surgeries are increasingly scheduled during nighttime or after-hours. This poses unique challenges, such as reduced staffing, disrupted circadian rhythms, and increased fatigue, which may potentially affect outcomes. Despite growing evidence on the impact of daytime on cardiac surgery outcome, results remain inconclusive. The current study aims to investigate a potential association between surgery timing (daytime: 7:00 AM to 7:00 PM vs. nighttime: 7:00 PM to 7:00 AM) and long-term survival in patients undergoing elective CABG.</p><p><strong>Methods: </strong>In this retrospective single-institution cohort study at the University Clinic Salzburg, Austria, we analyzed elective CABG surgeries performed between January 1, 2017, and December 31, 2021. The primary hypothesis was that nighttime elective CABG surgeries have worse long-term survival. Among 2,179 cardiac surgical procedures, 723 elective CABG surgeries were identified and analyzed. Long-term survival was assessed using Cox proportional hazard modeling, while secondary outcomes, including 30-day and one-year mortality rates, were evaluated through multiple linear regression analysis.</p><p><strong>Results: </strong>The one-year mortality rate was 2.6% (n = 19) for the observation period. Of the 723 patients, 646 (89.35%) underwent daytime surgery, and 77 (10.65%) had nighttime surgery. The median EuroScore II was 1.50 [1.00, 2.60] for daytime surgeries and 1.70 [1.10, 3.10] for nighttime surgeries (p = 0.111). There was no association between nighttime surgery and long-term mortality (aHR: 1.624, 95% CI: 0.589 to 3.662, p = 0.3179). Multivariable logistic regression analysis confirmed that nighttime surgeries were not significantly associated with increased one-year mortality (aOR: 1.089, 95% CI: 0.208 to 3.711, p = 0.905). No deaths occurred within 30 days in either group.</p><p><strong>Conclusion: </strong>This analysis found no significant association between nocturnal elective CABG operations and increased long-term or one-year mortality. This study did not aim to evaluate the economics of nocturnal surgeries at the investigated institution. To confirm our results that there is no increased morbidity and mortality associated with nocturnal CABG operations, and to understand the economic impact of nocturnal surgeries, prospective randomized studies would be necessary.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"19 1","pages":"8"},"PeriodicalIF":2.6,"publicationDate":"2025-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11912614/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143651412","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}