Patient Safety in Surgery最新文献

Aims: 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.

Methods: A retrospective analysis of patients undergoing body contouring and breast reconstruction procedures from January 1, 2022 to November 1, 2024 was performed.

Results: 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.

Conclusions: 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.

Background: 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.

Case description: 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.

Conclusion: 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.

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

Surgical handover remains a high-risk process with no gold standard for practice despite 20 years of available guidance. Variability in practice is common, and poorly performed handover poses significant, yet avoidable, risk to patients. Research in this domain is underfunded with widely heterogenous methodology, meaning that the evidence base for better handover is deficient. In this correspondence, recommendations are made to address these shortcomings, including standardised operating procedures supported by electronic health records to enable staff training and audit. Prioritisation of the sickest patients at the handover outset and two-way, verbal communication, including a "read-back" to confirm that information is both transmitted and received. Rigorous evaluation of handover interventions before use, and discontinuation of practices that add no value. Lastly, a core outcome set for surgical handover is urgently needed to improve the comparability of studies. By clearly defining best practices and demonstrating the impact of interventions on patient outcomes, surgeons will be more inclined to adopt meaningful improvements in handover processes.

Background: Failure-to-rescue refers to the rate of failure amongst healthcare teams in reversing complications that occur during a patient's hospitalization. This study aimed to investigate the failure-to-rescue rate following coronary artery bypass grafting (CABG).

Methods: Cross-sectional cohort study of the multicenter database "Registro Paulista de Cirurgia Cardiovascular II" (REPLICCAR II), which includes data from nine reference centers for cardiac surgery in São Paulo State. The study population included patients > 18 years of age who had undergone primary and isolated CABG surgery between 2017 and 2019 in Brazil. The outcome measured was failure-to-rescue (including death and the development of postoperative complications: prolonged ventilation time, stroke, reoperation, and kidney injury). The study used the Society of Thoracic Surgeons (STS) risk score to calculate the expected complication rates.

Results: Out of the 3964 patients, 439 developed one or more of the analyzed complications, and out of those, 94 died (2.37% of the full sample). The standardized mortality ratio (SMR) for patients who developed one complication was 8.84% (10.7%/1.21%), whereas those with two combinations of complications had an SMR of 32.34% (53.68%/1.66%) and three complications had an SMR of 42.02% (50%/1.19%). However, patients who progressed without the analyzed complications had an SMR of 0.95% (0.74%/0.80%).

Conclusion: The REPLICCAR II database revealed a failure-to-rescue rate of 21.41% (94/439), and the SMR increased progressively according to the greater number of complications. Our findings emphasize the need to measure the impact of early diagnosis and effective hospital team response by parameterizing the risk of expected death after severe complications.

Trial registration: The REPLICCAR Registry and The Statewide Quality Improvement Initiative, ID NCT05363696.

Background: Meniscal surgery is one of the most frequent orthopaedic procedures performed worldwide. There is a wide range of possible treatment errors that can occur following meniscal surgery. In Norway, patients subject to treatment errors by hospitals and private institutions can file a compensation claim free of charge to the Norwegian System of Patient Injury Compensation (NPE). The purpose of this study was to systematically analyse compensation claims filed to the NPE following meniscal surgery and evaluate gender effects on accepted claims. Our hypothesis was that there was no gender difference in accepted claims.

Methods: We performed a cross-sectional study assessing all registered claims at the NPE after meniscal surgery from 2010 to 2020. The surgical procedures were stratified into subgroups following data collection. Data from the Norwegian Patient Registry were collected to obtain information on the numbers of the different procedures performed in hospitals and private institutions. We calculated frequencies and relative frequencies of categorical data. Differences in categorical data were calculated using the Pearson Chi-square test.

Results: The total number of meniscal resections and sutures in the study period was 119,528. A total of 372 compensation claims were filed, 241 male and 130 female. Of these, 152 (40.9%) claims were accepted, while 220 (59.1%) were rejected. The most frequent reasons for filing a compensation claim were pain (114), followed by infection (98), wrong technique (38) and impaired function/instability (25).There was a significant gender difference in the acceptance of claims in favour of men (121 vs. 31, p < 0.001). A sensitivity analysis excluding infection as reason for compensation claim found no gender difference (p = 0.16) in acceptance of claims.

Conclusion: Compensation claims after meniscal surgery are rare, with only 0.3% of patients filing a compensation claim. There was a marked preponderance of men with accepted claims due to a higher frequency of postoperative infections. Surgeons should be aware of this and take this into account in the decision-making before surgery.

Background: Colorectal surgery is associated with a high risk of postoperative complications, including technical complications, surgical site infections, and other adverse events affecting patient safety and overall patient experience. "Enhanced Recovery After Surgery" (ERAS) is considered a new standard of care for streamlining the perioperative care of surgical patients with the goal of minimizing complications and optimizing timely patient recovery after surgery. This systematic review was designed to investigate the evidence-based literature pertinent to comparing patient outcomes after ERAS versus conventional perioperative care.

Methods: This systematic review evaluates the performance of ERAS protocols against conventional care in colorectal surgery, focusing on various postoperative outcome measures. An extensive search was conducted across multiple electronic databases and registers from July 2 to July 5, 2024, complemented by citation searching on November 30, 2024. This approach led to the identification of 11 randomized controlled trials (RCTs) from the past decade, involving 1,476 adult participants. To ensure methodological rigor and transparency, the review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines and was registered with PROSPERO (CRD42024583074).

Results: The implementation of ERAS protocols resulted in a notable decrease in hospital stay duration compared to conventional care, with reductions varying between 3 and 8 days across studies. ERAS patients also had faster gastrointestinal recovery, including quicker times to bowel movement, defecation, and resumption of normal diet. Furthermore, patients in ERAS groups showed notably reduced postoperative complications and opioid consumption, with patients experiencing lower pain scores on the Visual Analogue Scale (VAS) and reduced reliance on opioids. Additionally, nutritional recovery in ERAS patients was enhanced, with elevated albumin and total protein levels, alongside decreased inflammatory markers and improved immune function.

Conclusion: This systematic review provides compelling evidence supporting the integration of ERAS protocols into standard colorectal surgical practices. Future studies should aim to explore the variations in ERAS implementation, pinpoint the most impactful elements of ERAS, and work towards personalizing and standardizing these protocols across clinical settings. Additionally, evaluating long-term outcomes will help refine ERAS strategies, ensuring their enduring impact on patient recovery.