Analysis of orthopedic surgery-related incidents in operating rooms using a nationwide incident reporting database.

IF 1.5 4区 医学 Q3 ORTHOPEDICS Journal of Orthopaedic Science Pub Date : 2024-10-14 DOI:10.1016/j.jos.2024.09.008
Shiho Nakano, Toshiaki Kotani, Arata Nakajima, Masato Sonobe, Kayo Inakuma, Seiji Ohtori, Koichi Nakagawa
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Abstract

Background: Patient safety is crucial in high-risk specialties such as orthopedic surgery due to the significant incidence of preventable adverse events. Analyzing extensive databases of orthopedic surgery-related incidents in operating rooms is vital for enhancing medical safety and identifying targeted interventions. This study analyzed orthopedic surgery-related incidents in operating rooms using a nationwide incident reporting database in Japan to identify risk factors associated with severe harm.

Methods: We extracted orthopedic surgery-related incidents in the operating room from the Japan Council for Quality Health Care's database, which contained 127,207 near-miss and adverse event reports recorded between January 1, 2010 and September 30, 2022. We analyzed 882 incident cases, focusing on patient demographics, incident timing, surgical site, incident causes, and severity levels.

Results: The most incidents involved surgeons (93.3 %) with an average of 16.0 ± 8.5 years of experience. The frequent causes were "failure to check" (48.0 %) and "misjudgment" (24.0 %), which were non-technical errors. "Errors in methods/procedures" accounted for 37.1 % of incidents, possibly due to a wide variety of surgical approaches and implants used in orthopedic surgeries. Regarding severity, 86 % were critical incidents that threatened patients' livelihoods or lives. Surgeries involving surgeons had a significantly higher risk of severe harm than those involving healthcare professionals other than surgeons (odds ratio: 3.311, 95 % confidence interval: 1.858-5.901).

Conclusions: This study revealed that most of orthopedic surgery-related incidents in operating rooms involved experienced surgeons and resulted in severe patient harm. The frequent causes were failure to check, misjudgment, and errors in methods/procedures. These highlight the crucial role of orthopedic surgeons in actively contributing to medical safety databases and fostering a culture of reporting within their field.

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利用全国性事故报告数据库分析手术室中与骨科手术相关的事故。
背景:由于可预防不良事件的发生率很高,患者安全在骨科手术等高风险专科中至关重要。分析手术室骨科手术相关事故的大量数据库对于提高医疗安全和确定有针对性的干预措施至关重要。本研究利用日本全国性事故报告数据库分析了手术室骨科手术相关事故,以确定与严重伤害相关的风险因素:我们从日本医疗保健质量委员会的数据库中提取了手术室中与骨科手术相关的事故,该数据库包含 2010 年 1 月 1 日至 2022 年 9 月 30 日期间记录的 127,207 份险情和不良事件报告。我们分析了 882 个事故案例,重点关注患者人口统计学、事故发生时间、手术部位、事故原因和严重程度:大多数事故涉及外科医生(93.3%),他们的平均工作经验为 16.0 ± 8.5 年。最常见的原因是 "未检查"(48.0%)和 "误判"(24.0%),这些都是非技术性错误。"方法/程序错误 "占 37.1%,这可能是由于骨科手术中使用的手术方法和植入物种类繁多。就严重程度而言,86%的事故属于危及患者生计或生命的重大事故。涉及外科医生的手术发生严重伤害的风险明显高于涉及外科医生以外的医护人员的手术(几率比:3.311,95%置信区间:1.858-5.901):这项研究表明,手术室中大多数骨科手术相关事故都涉及经验丰富的外科医生,并导致了对患者的严重伤害。经常发生的原因是检查不到位、判断失误和方法/程序错误。这凸显了骨科外科医生在积极为医疗安全数据库做贡献和在其领域内培养报告文化方面的关键作用。
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来源期刊
Journal of Orthopaedic Science
Journal of Orthopaedic Science 医学-整形外科
CiteScore
3.00
自引率
0.00%
发文量
290
审稿时长
90 days
期刊介绍: The Journal of Orthopaedic Science is the official peer-reviewed journal of the Japanese Orthopaedic Association. The journal publishes the latest researches and topical debates in all fields of clinical and experimental orthopaedics, including musculoskeletal medicine, sports medicine, locomotive syndrome, trauma, paediatrics, oncology and biomaterials, as well as basic researches.
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