Patient Safety in Surgery最新文献

{"title":"Prevalence of malpractice claims after arthroscopic shoulder surgery: analysis of 69,097 procedures from a national registry in Norway.","authors":"Ola Midtsaether Lian, Per-Henrik Randsborg, Rune Bruhn Jakobsen, Ida Rashida Khan Bukholm, Tommy Frøseth Aae","doi":"10.1186/s13037-023-00378-5","DOIUrl":"10.1186/s13037-023-00378-5","url":null,"abstract":"<p><strong>Background: </strong>Systematic analysis of compensation claims following patient injuries is helpful in improving patient safety. The objective of the current study was to assess compensation claims after arthroscopic treatment of rotator cuff ruptures, impingement, and acromioclavicular joint osteoarthritis reported to the Norwegian System of Patient Injury Compensation and evaluate if there was regional variation on the risk of patient injuries leading to an accepted compensation claim.</p><p><strong>Methods: </strong>Data from the Norwegian System of Patient Injury Compensation and the Norwegian Patient Registry (NPR) from 2008 to 2018 were collected. Demographics (age and sex) and type of claim and reasons for accepted claims were obtained from the Norwegian System of Patient Injury Compensation, while the number of arthroscopic procedures was collected from NPR. The treating institutions were grouped on geography according to Norway's four regional Health Trusts and private institutions and the effect of geography on the probability of an accepted claim was estimated.</p><p><strong>Results: </strong>NPR registered 69,097 shoulder arthroscopies during the study period, of which 216 (0.3%) compensation claims were filed for patient injury. A total of 38% of the claims were accepted, representing 0.1% of the arthroscopic procedures. Infection (37.8%) was the most common reason for accepted claim, followed by no surgical indication (15.9%) and wrong surgical technique (12.2%). We found a statistically significantly increased odds ratio for a claim being accepted in both the smallest and largest regional Health Trusts compared to the other regional Health Trusts and private institutions.</p><p><strong>Conclusions: </strong>Compensation claims due to patient injury following shoulder arthroscopy are rare (0.3% of patients file a claim, of which a third is accepted (0.1% of all shoulder arthroscopy patients)). The most common reason for accepted claim was infection followed by lack of indication.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"25"},"PeriodicalIF":3.7,"publicationDate":"2023-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10585783/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49683499","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":"Incidence and root causes of surgery cancellations at an academic medical center in Iran: a retrospective cohort study on 29,978 elective surgical cases.","authors":"Vida Naderi-Boldaji, Mahsa Banifatemi, Raheleh Zandi, Mohammad Hossein Eghbal, Milad Nematollahi, Mohammad Ali Sahmeddini","doi":"10.1186/s13037-023-00377-6","DOIUrl":"10.1186/s13037-023-00377-6","url":null,"abstract":"<p><strong>Introduction: </strong>Canceling scheduled surgeries on the day of surgery places a heavy burden on healthcare providers and has psychological, social, and financial consequences on patients and their families. This study aimed to investigate the main reasons for cancellations of elective procedures and provide appropriate recommendations to reduce the rate of such avoidable cancellations.</p><p><strong>Methods: </strong>Data were collected retrospectively from all consecutive elective cases scheduled for various elective surgeries from January 1, 2020 to March 31, 2022 at Namazi Teaching Hospital, a major referral center in southern Iran with a capacity of 938 beds. Daily data were collected on the number of planned electives, cancellations, and reasons for cancellations. Surgical cancellation reasons were categorized as patient-related, surgeon-related, hospital/system-related, and anesthesia-related. Data were expressed as frequency (percentage) and analyzed with SPSS version 19 software.</p><p><strong>Results: </strong>The cancellation rate on surgery day for elective procedures in all fields was 6.3%. The highest cancellation rate was related to minor surgeries (19%), followed by urology (8%), pediatrics (7%), and plastic surgery (7%). The most common reasons for cancellation were patients not suitable for the procedure (37%), followed by patients who did not follow instructions (10%), lack of time (10.5%), and equipment/supplies problems (10%), and refusal to consent (6%).</p><p><strong>Conclusions: </strong>According to this study, patients' unsuitability for surgery, non-compliance with instructions, lack of time, and problems with equipment/supplies are the main reasons for canceling surgery. Proper preoperative assessment and preparation of patients and improved communication between medical teams and patients reduce the cancellation of booked surgeries.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"24"},"PeriodicalIF":3.7,"publicationDate":"2023-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10481593/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10187810","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 Safety in Surgery - announcing the journal's first impact factor (3.7).","authors":"Philip F Stahel, Sebastian Weckbach, Navid Ziran, Wade R Smith, Ernest E Moore, Hans-Christoph Pape, Pierre-Alain Clavien","doi":"10.1186/s13037-023-00375-8","DOIUrl":"10.1186/s13037-023-00375-8","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"22"},"PeriodicalIF":3.7,"publicationDate":"2023-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10466761/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10118235","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":"The safety of telemedicine clinics as an alternative to in-person preoperative assessment for elective laparoscopic cholecystectomy in patients with benign gallbladder disease: a retrospective cohort study.","authors":"Tomas Urbonas, Adil Siraj Lakha, Emily King, Sophia Pepes, Carlo Ceresa, Venkatesha Udupa, Zahir Soonawalla, Michael A Silva, Alex Gordon-Weeks, Srikanth Reddy","doi":"10.1186/s13037-023-00368-7","DOIUrl":"10.1186/s13037-023-00368-7","url":null,"abstract":"<p><strong>Background: </strong>The telemedicine clinic for follow up after minor surgical procedures in general surgery is now ubiquitously considered a standard of care. However, this method of consultation is not the mainstay for preoperative assessment and counselling of patients for common surgical procedures such as laparoscopic cholecystectomy. The aim of this study was to evaluate the safety of assessing and counselling patients in the telemedicine clinic without a physical encounter for laparoscopic cholecystectomy.</p><p><strong>Methods: </strong>We conducted a retrospective analysis of patients who were booked for laparoscopic cholecystectomy for benign gallbladder disease via general surgery telemedicine clinics from March 2020 to November 2021. The primary outcome was the cancellation rate on the day of surgery. The secondary outcomes were complication and readmission rates, with Clavein-Dindo grade III or greater deemed clinically significant. We performed a subgroup analysis on the cases cancelled on the day of surgery in an attempt to identify key reasons for cancellation following virtual clinic assessment.</p><p><strong>Results: </strong>We identified 206 cases booked for laparoscopic cholecystectomy from telemedicine clinics. 7% of patients had a cancellation on the day of surgery. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. Severe postoperative adverse events (equal to or greater than Clavien-Dindo grade III) were observed in 1% of patients, and required re-intervention. 30-day readmission rate was 11%.</p><p><strong>Conclusions: </strong>Our series showed that it is safe and feasible to assess and counsel patients for laparoscopic cholecystectomy remotely with a minimal cancellation rate on the day of operation. Further work is needed to understand the effect of remote consultations on patient satisfaction, its environmental impact, and possible benefits to healthcare economics to support its routine use in general surgery.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"23"},"PeriodicalIF":3.7,"publicationDate":"2023-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10466851/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10127762","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":"The relationship between patient safety culture and adverse events in Iranian hospitals: a survey among 360 nurses.","authors":"Saeideh Moosavi,&nbsp;Mohammad Amerzadeh,&nbsp;Mohammad Azmal,&nbsp;Rohollah Kalhor","doi":"10.1186/s13037-023-00369-6","DOIUrl":"https://doi.org/10.1186/s13037-023-00369-6","url":null,"abstract":"<p><strong>Background: </strong>Adverse events have become a global problem and are an important indicator of patient safety. Patient safety culture is essential in efforts to reduce adverse events in the hospital. This study aimed to investigate the status of the patient safety culture, the frequency of adverse events, and the relationship between them in Qazvin's hospitals in Iran.</p><p><strong>Methods: </strong>The present study is a descriptive-analytical study conducted in six hospitals in Qazvin, Iran, in 2020. The study population was nurses working in Qazvin hospitals. We collected data via a patient safety culture questionnaire and an adverse event checklist. Three hundred sixty nurses completed questionnaires. Multiple logistic regression was used to investigate the relationship between variables.</p><p><strong>Results: </strong>The highest mean of patient safety culture was related to the organizational learning dimension (3.5, SD = .074) and feedback and communication about errors (3.4, SD = 0.82). The participants gave the lowest score to dimensions of exchanges and transfer of information (2.45,=0.86) and management support for patient safety (2.62,Sd = 0.65). Management's support for patient safety, general understanding of patient safety culture, teamwork within organizational units, communication and feedback on errors, staff issues, and information exchange and transfer were significant predictors of adverse events.</p><p><strong>Conclusion: </strong>This study confirms patient safety culture as a predictor of adverse events. Healthcare managers should provide the basis for improving the patient safety culture and reducing adverse events through methods such as encouraging the reporting of adverse events and also holding training courses for nurses.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"20"},"PeriodicalIF":3.7,"publicationDate":"2023-07-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10373364/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10263195","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":"Management strategies and root causes of missed iatrogenic intraoperative ureteral injuries with delayed diagnosis: a retrospective cohort study of 40 cases.","authors":"Selim Zaghbib,&nbsp;Ahmed Saadi,&nbsp;Hamza Boussaffa,&nbsp;Haroun Ayed,&nbsp;Mohamed Riadh Ben Slama","doi":"10.1186/s13037-023-00372-x","DOIUrl":"https://doi.org/10.1186/s13037-023-00372-x","url":null,"abstract":"<p><strong>Background: </strong>Intraoperative iatrogenic ureteral injuries represent rare technical surgical complications with the potential for adverse patient outcomes, particularly when the diagnosis is delayed. Ideally, these technical complications are recognized and repaired intraoperatively. This study was designed to investigate the root causes and outcomes of missed intraoperative ureteral injuries at a tertiary urology referral centre in Tunisia.</p><p><strong>Methods: </strong>This is a retrospective cohort study in a tertiary urology referral centre in Tunis from January 1^st, 2015, to December 31^st, 2020, including all patients with iatrogenic ureteral injury, not diagnosed intraoperatively. The factors associated with the success of endoscopic treatment and those associated with the unfavourable evolution were investigated.</p><p><strong>Results: </strong>A total of 40 iatrogenic ureteral injuries were included. Gynaecological surgery was responsible for 85% of ureteral injuries, mainly during hysterectomies (55%). The symptoms were dominated by low back pain (37.5%) and pyelonephritis (25%). Endoscopic treatment was attempted in 22 cases, it was sufficient in 12 cases. Ureteral injury required surgical treatment in 24 cases, and ureteroneocystostomy was performed in 16 cases. Nephrectomy was performed in eight cases, representing 20% of injuries, including three cases as the first treatment for late-diagnosed cases with a destroyed kidney. In the analytical study, endoscopic treatment was sufficient in 50% in case of ureteral fistula versus 27% in case of ureteral stenosis (p = 0.04). Nephrectomy was performed in 10% of cases when ureteral injury was diagnosed within the first month postoperatively compared to 60% of cases when this delay exceeded one month (p = 0.004).</p><p><strong>Conclusion: </strong>Iatrogenic ureteral injuries discovered postoperatively are mostly secondary to gynaecologic surgery. Although endoscopic treatment is usually performed as a first treatment, a more aggressive surgical is often necessary, with a nephrectomy rate of 20%.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"21"},"PeriodicalIF":3.7,"publicationDate":"2023-07-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10373270/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9877408","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":"March 2020-Printed Issue","authors":"","doi":"10.33940/001c.84520","DOIUrl":"https://doi.org/10.33940/001c.84520","url":null,"abstract":"The spring 2020 issue of Patient Safety is available to read online and download at no charge. Each issue of Patient Safety brings you the latest evidence-based research and data analytics, interviews with healthcare experts and advocates, thought-provoking editorials, and inspiring stories from patients and families. Our cover story, “I Am the Zebra,” (https://patientsafetyj.com/article/73585-i-am-the-zebra-one-woman-s-five-year-quest-for-the-truth) is a patient commentary from Missy Adams and her husband, Solomon, detailing her long, difficult journey toward an accurate diagnosis. In this issue we also hear from Mary Ellen Mannix, who shares the tragic story of her son James (https://patientsafetyj.com/article/73597-one-on-one-mary-ellen-mannix) and how her efforts to understand what happened to him led her to speak up for other patients. Additional highlights: A practice improvement paper about an organization’s efforts to decrease medication errors (https://patientsafetyj.com/article/73587) related to patient weight discrepancies, a new safety self-assessment tool (https://patientsafetyj.com/article/73589) to help prevent vancomycin-related events, and a look at how safety is compromised when hospital equipment cannot accommodate obese patients (https://patientsafetyj.com/article/73590). Members of the LGBTQ community tell us in their own words about their healthcare experiences (https://patientsafetyj.com/article/73592) and how we can provide safe care for all patients, and we celebrate the winners of the Patient Safety Authority’s 2020 I AM Patient Safety Awards (https://patientsafetyj.com/article/73593). Patient Safety is fully open access (no fees for authors or readers). We welcome manuscripts from all over the world. If your work can help advance patient safety, please submit it to us for consideration (https://patientsafetyj.com/for-authors), and kindly share our journal with friends, family, colleagues, and caregivers.","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"184 1","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85666573","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Delayed intestinal obstruction from an unintentionally retained surgical gauze in a 24-year old woman two years after caesarean section: a case report.","authors":"Samir Ismail Bashir,&nbsp;Yasir Babiker Ali,&nbsp;Elsadig Mohamed Ali,&nbsp;Hiba Awadelkareem Osman Fadl,&nbsp;Abdelrahman Hamza Abdelmoneim Hamza,&nbsp;Mohammed Mahmmoud Fadelallah Eljack","doi":"10.1186/s13037-023-00371-y","DOIUrl":"10.1186/s13037-023-00371-y","url":null,"abstract":"<p><strong>Background: </strong>One of the most common surgical emergencies, intestinal obstruction is rarely the result of an inadvertently retained foreign object (also known as a gossypiboma), which may not present symptoms for a lifetime. It also carries additional legal burdens, which may account for the rarity of its reports.</p><p><strong>Case presentation: </strong>We report a 24-year-old Sudanese female with a history of emergency Caesarean section two years before the admission presented with abdominal distension and absolute constipation, which was diagnosed as intestinal obstruction with a retained gauzed found within the small intestine. Moreover, a review of recent African-reported cases was done to find relatively similar cases.</p><p><strong>Conclusion: </strong>Adhering to the standard of care in surgical theaters and integrating new methods of prevention like tagged gauze could help to decrease the rate of such cases in the future.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"19"},"PeriodicalIF":3.7,"publicationDate":"2023-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10362721/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9912144","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":"December 2019-Printed Issue","authors":"","doi":"10.33940/001c.84463","DOIUrl":"https://doi.org/10.33940/001c.84463","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"464 ","pages":""},"PeriodicalIF":3.7,"publicationDate":"2023-07-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72505611","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Surgical residents as \"second victims\" following exposure to medical errors in a tertiary health training facility in Nigeria: a phenomenology study.","authors":"James Ayokunle Balogun,&nbsp;Adefisayo Ayoade Adekanmbi,&nbsp;Folusho Mubowale Balogun","doi":"10.1186/s13037-023-00370-z","DOIUrl":"https://doi.org/10.1186/s13037-023-00370-z","url":null,"abstract":"<p><strong>Introduction: </strong>The \"second victim\" phenomenon refers to the distress and other negative consequences that physicians experience when they commit medical error. There has been increasing awareness about this phenomenon and efforts are being made to address it. However, there is dearth of information about it in developing countries. This study explored the experiences of surgical resident doctors of the University College Hospital in Ibadan, Nigeria about the \"second victim\" phenomenon and the support they had following medical errors.</p><p><strong>Methods: </strong>This is a phenomenology study in which qualitative data were obtained from interviews with 31 resident doctors across 10 surgical units/departments. Interviews were transcribed verbatim, and data were coded inductively. Data were analyzed using content analysis method. Themes and subthemes were generated using axial coding. The themes were then integrated using selective coding.</p><p><strong>Results: </strong>There were 31 participants and 10(32.3%) were females. All had witnessed other physicians encountering medical errors while 28(90.3%) had been directly involved in medical errors. Most of the errors were at the inter-operative stage. Prolonged work hours with inadequate sleep were identified as major causes of most medical errors. The feelings following medical errors were all negative and was described as 'stressful'. Most of the residents got support from their colleagues, mostly contemporaries following medical errors, and many viewed medical errors as a learning point to improve their practice. However, there was a general belief that the systemic support following medical errors was inadequate.</p><p><strong>Conclusion: </strong>The \"second victim\" phenomenon was common among the study group with consequent negative effects. Normalizing discussions about medical errors, reduction of work hours and meticulous intraoperative guidance may reduce medical errors and its consequences on the surgical residents. Steps should be taken within the system to address this issue effectively.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"17 1","pages":"18"},"PeriodicalIF":3.7,"publicationDate":"2023-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10353142/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9834599","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}