James J Jung1, Robert Chris Adams-McGavin2, Teodor P Grantcharov3. 1. International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada. Electronic address: jungj@smh.ca. 2. International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada. 3. International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Abstract
BACKGROUND: Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events. MATERIALS AND METHODS: Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries. RESULTS: Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts. CONCLUSIONS: Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review.
BACKGROUND: Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events. MATERIALS AND METHODS: Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries. RESULTS: Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts. CONCLUSIONS: Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review.
Authors: Moritz Spiller; Marcus Bruennel; Victoria Grosse; Thomas Sühn; Nazila Esmaeili; Jessica Stockheim; Salmai Turial; Roland Croner; Axel Boese; Michael Friebe; Alfredo Illanes Journal: BMC Surg Date: 2022-07-19 Impact factor: 2.030