Colorectal surgeons' learning curve of transanal endoscopic microsurgery.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is a technically demanding key technique in minimally invasive rectal surgery. We investigated the learning curve of colorectal surgeons commencing with TEM. METHODS: All TEM procedures of four colorectal surgeons were analyzed. Procedures were ranked chronologically per surgeon. Outcomes included conversion, postoperative complications, procedure time, and recurrence. Backward multivariable regression analysis identified learning curve effects and other predictors. RESULTS: Four surgeons resected 693 rectal lesions [69.9 % adenoma/25.5 % carcinoma; median size 20 cm(2); interquartile range (IQR) 11-35; 7 ± 4 cm ab ano]. A total of 555 resections (80.1 %) were histopathologically radical (R0). Conversion (4.3 %) was influenced by a learning curve [odds ratio (OR) 0.991 per additional procedure; 95 % confidence interval (CI) 0.984-0.998] and by lesion size. Postoperative complications depended only on the individual surgeon and lesion size in benign lesions (10.4 % complications). A learning curve (OR 0.99; 95 % CI 0.988-0.998) and peritoneal entrance affected complications in malignant lesions (13.3 %). Procedure time [median 55 min (IQR 30-90)] was influenced by a learning curve [B -0.11 (95 % CI -0.14 to -0.09)], individual surgeon, single-piece resection, peritoneal entrance, lesion size, and rectal quadrant. Recurrence of benign lesions (4.5 %) depended on lesion size, R0 resection, and prior resection attempts. Recurrence of malignant lesions (8.9 %) depended on 3D stereoscopic view, lesion size, full-thickness resection, and length of follow-up. Recurrence-free survival of patients operated during the 36th through 80th procedure per surgeon was significantly shorter than in patients operated during procedures 1-35 and 81 onwards. CONCLUSIONS: A surgical learning curve affected conversion rate, procedure time, and complication rate. It did not influence recurrence rates, possibly due to evolving patient populations. This first insight into the learning curve of TEM stresses the importance of quality monitoring and centralisation of care.

Effects on incident reporting after educating residents in patient safety: a controlled study.

BACKGROUND: Medical residents are key figures in delivering health care and an important target group for patient safety education. Reporting incidents is an important patient safety domain, as awareness of vulnerabilities could be a starting point for improvements. This study examined effects of patient safety education for residents on knowledge, skills, attitudes, intentions and behavior concerning incident reporting. METHODS: A controlled study with follow-up measurements was conducted. In 2007 and 2008 two patient safety courses for residents were organized. Residents from a comparable hospital acted as external controls. Data were collected in three ways: 1] questionnaires distributed before, immediately after and three months after the course, 2] incident reporting cards filled out by course participants during the course, and 3] residents' reporting data gathered from hospital incident reporting systems. RESULTS: Forty-four residents attended the course and 32 were external controls. Positive changes in knowledge, skills and attitudes were found after the course. Residents' intentions to report incidents were positive at all measurements. Participants filled out 165 incident reporting cards, demonstrating the skills to notice incidents. Residents who had reported incidents before, reported more incidents after the course. However, the number of residents reporting incidents did not increase. An increase in reported incidents was registered by the reporting system of the intervention hospital. CONCLUSIONS: Patient safety education can have immediate and long-term positive effects on knowledge, skills and attitudes, and modestly influence the reporting behavior of residents.

Residents' intentions and actions after patient safety education.

BACKGROUND: Medical residents are key figures in delivering care and an important target group for patient safety education. The objective of this study was to assess residents' intentions and actions concerning patient safety improvement after patient safety education. METHODS: Four multi-specialty 2-day patient safety courses were organized, in which residents from five Dutch hospitals participated. At the end of these courses participants were asked to formulate an action point to improve patient safety. Three months later semi-structured interviews were conducted to reveal actions that were taken, factors that had influenced their behaviour and reactions concerning the education. An inductive theory approach was used to analyze transcriptions. RESULTS: Out of 71 participants, sixty-nine (97%) residents were interviewed. In total they had formulated 91 action points, which mainly focused on: 'Improving organization of own work/Follow policies' and 'Improving culture/Educating colleagues about patient safety'. Sixty-two (90%) residents declared to have taken action, and 50 (55%) action points were fully carried out. Most actions taken were at the level of the individual professional, rather than at the level of their social or organizational context. Results of actions included adjusting the structure of their own work, organizing patient safety education for colleagues, communicating more efficiently and in a more structured way with colleagues, and reporting incidents. Promoters for action included: 'Awareness of the importance of the action to be taken', 'Supportive attitude of colleagues' and 'Having received patient safety education'. Barriers included: 'Impeding attitude of colleagues', 'High work-pressure', 'Hierarchy' and 'Switching of work stations'. CONCLUSIONS: After patient safety training, residents reported various intentions to contribute to patient safety improvement. Numerous actions were taken, but there still is a discrepancy between intentions and actual behaviour. To increase residents' participation in patient safety improvement, educational efforts should be supplemented with actions to remove experienced barriers, most of which are related to the residents' social and organizational context.

Do specialty registrars change their attitudes, intentions and behaviour towards reporting incidents following a patient safety course?

BACKGROUND: Reporting incidents can contribute to safer health care, as an awareness of the weaknesses of a system could be considered as a starting point for improvements. It is believed that patient safety education for specialty registrars could improve their attitudes, intentions and behaviour towards incident reporting. The objective of this study was to examine the effect of a two-day patient safety course on the attitudes, intentions and behaviour concerning the voluntary reporting of incidents by specialty registrars. METHODS: A patient safety course was designed to increase specialty registrars' knowledge, attitudes and skills in order to recognize and cope with unintended events and unsafe situations at an early stage. Data were collected through an 11-item questionnaire before, immediately after and six months after the course was given. RESULTS: The response rate at all three points in time assessed was 100% (n = 33). There were significant changes in incident reporting attitudes and intentions immediately after the course, as well as during follow-up. However, no significant changes were found in incident reporting behaviour. CONCLUSIONS: It is shown that patient safety education can have long-term positive effects on attitudes towards reporting incidents and the intentions of registrars. However, further efforts need to be undertaken to induce a real change in behaviour.

Waiting for elective general surgery: physical, psychological and social consequences.

BACKGROUND: Long surgical waiting lists are common and receive serious consideration. To evaluate the positive and negative effects of waiting lists, insight into the consequences of waiting is needed. The present study aims to assess what insight the current literature provides into the effects of delayed surgery for varicose veins, inguinal hernia in adults, gallstones, and breast cancer in terms of physical, psychological and social aspects. METHODS: Searches of Medline and Embase, for the period January 1985-September 2003, were performed to identify articles providing direct or indirect insight into the consequences of waiting for surgery for each disorder. Reference lists of retrieved reports were examined for relevant articles. RESULTS: Seven studies were identified with direct data on consequences of delay in elective surgery. Relevant indirect data were found in 32 reports. Results indicated that delayed varicose vein surgery or inguinal hernia repair involves marginal physical, psychological or social suffering, and that severe deterioration is unlikely. The impact of delayed cholecystectomy seems more profound by suffering on all three health aspects. Complications while waiting do occur, with a higher risk for patients with previous complications. Longer delays for breast cancer surgery seem to adversely affect prognosis, although it is unclear which interval is associated with such an effect. Moreover, having breast cancer undoubtedly affects psychological health. CONCLUSIONS: There is a remarkable paucity of studies addressing the consequential impact of waiting for elective surgery on patients' health for each of the four studied disorders. Current literature permits merely general estimation of this consequential impact. As specific assessment of these consequences is important for daily practice and for policy, further research is required.

A patient safety curriculum for medical residents based on the perspectives of residents and supervisors.

OBJECTIVES: To develop a patient safety course for medical residents based on the views of medical residents and their supervisors. METHODS: In 2007, questionnaires were distributed to investigate residents' and supervisors' perspectives on the current patient safety performance and educational needs of residents. These perspectives were categorized according to the factors that influence daily practice as described in the London Protocol. Selection of course content and corresponding learning goals was made by an expert panel and based on the questionnaires' outcomes. RESULTS: One hundred sixteen (64%) respondents filled out the questionnaire. Residents rated health care as significantly safer than supervisors. Close links were found between described risks and expressed educational needs. Both were found to be predominantly related to team factors, work environmental factors, and individual factors. The principal course themes that were selected are as follows: (1) principles of patient safety, (2) human factors, (3) effective teamwork, (4) contribution to safer care, and (5) medicolegal aspects of patient safety. CONCLUSIONS: Residents are not fully aware of all potential risks of their work and of their own role in patient safety. This underlines the need for an explicit focus on patient safety issues during their training. A needs assessment among involved parties engages respondents in the process and can provide valuable input for developing patient safety education for residents.