Marko Simunovic1,2,3, Vanja Grubac4, Christopher Hillis5, Ilun Yang4, Cagla Eskicioglu4, Jessica Bogach4, Erin Kennedy6, Geoff Porter7, Christine Fahim8, James Wright5, Tariq Aziz9, Scott Tsai10, Christian B van der Pol10, P J Devereaux11, G R Baker12. 1. Department of Surgery, McMaster University, Hamilton, ON, Canada. simunovi@hhsc.ca. 2. Department of Oncology, McMaster University, Hamilton, ON, Canada. simunovi@hhsc.ca. 3. Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada. simunovi@hhsc.ca. 4. Department of Surgery, McMaster University, Hamilton, ON, Canada. 5. Department of Oncology, McMaster University, Hamilton, ON, Canada. 6. Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada. 7. Department of Surgery, Dalhousie University, Halifax, NS, Canada. 8. Li Ka Shing Knowledge Institute, Toronto, ON, Canada. 9. Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada. 10. Department of Radiology, McMaster University, Hamilton, ON, Canada. 11. Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada. 12. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
Abstract
BACKGROUND: For patients undergoing rectal cancer surgery, we evaluated whether suboptimal preoperative surgeon evaluation of resection margins is a latent condition factor-a factor that is common, unrecognized, and may increase the risk of certain adverse events, including local tumour recurrence, positive surgical margin, nontherapeutic surgery, and in-hospital mortality. METHODS: In this observational case series of patients who underwent rectal cancer surgery during 2016 in Local Health Integrated Network 4 region of Ontario (population 1.4 million), chart review and a trigger tool were used to identify patients who experienced the adverse events. An expert panel adjudicated whether each event was preventable or nonpreventable and identified potential contributing factors to adverse events. RESULTS: Among 173 patients, 25 (14.5%) had an adverse event and 13 cases (7.5%) were adjudicated as preventable. Rate of surgeon awareness of preoperative margin status was low at 50% and similar among cases with and without an adverse event (p = 0.29). Suboptimal surgeon preoperative evaluation of surgical margins was adjudicated a contributing factor in all 11 preventable local recurrence, positive margin, and nontherapeutic surgery cases. Failure to rescue was judged a contributing factor in the two cases with preventable in-hospital mortality. CONCLUSIONS: Suboptimal surgeon preoperative evaluation of surgical margins in rectal cancer is likely a latent condition factor. Optimizing margin evaluation may be an efficient quality improvement target.
BACKGROUND: For patients undergoing rectal cancer surgery, we evaluated whether suboptimal preoperative surgeon evaluation of resection margins is a latent condition factor-a factor that is common, unrecognized, and may increase the risk of certain adverse events, including local tumour recurrence, positive surgical margin, nontherapeutic surgery, and in-hospital mortality. METHODS: In this observational case series of patients who underwent rectal cancer surgery during 2016 in Local Health Integrated Network 4 region of Ontario (population 1.4 million), chart review and a trigger tool were used to identify patients who experienced the adverse events. An expert panel adjudicated whether each event was preventable or nonpreventable and identified potential contributing factors to adverse events. RESULTS: Among 173 patients, 25 (14.5%) had an adverse event and 13 cases (7.5%) were adjudicated as preventable. Rate of surgeon awareness of preoperative margin status was low at 50% and similar among cases with and without an adverse event (p = 0.29). Suboptimal surgeon preoperative evaluation of surgical margins was adjudicated a contributing factor in all 11 preventable local recurrence, positive margin, and nontherapeutic surgery cases. Failure to rescue was judged a contributing factor in the two cases with preventable in-hospital mortality. CONCLUSIONS: Suboptimal surgeon preoperative evaluation of surgical margins in rectal cancer is likely a latent condition factor. Optimizing margin evaluation may be an efficient quality improvement target.
Authors: Brian M Wong; Sonia Dyal; Edward E Etchells; Sandra Knowles; Lauren Gerard; Artemis Diamantouros; Rajin Mehta; Barbara Liu; G Ross Baker; Kaveh G Shojania Journal: BMJ Qual Saf Date: 2015-03-06 Impact factor: 7.035