Medication Errors in Surgery: A Classification Taxonomy and a Pilot Study in Postcall Residents.

INTRODUCTION: The post-call state in postgraduate medical trainees is associated with impaired decision-making and increased medical errors. An association between post-call state and medication prescription errors for surgery residents is yet to be established. Our objective was to determine whether post-call state is associated with increased proportion of medication prescription errors committed by surgery residents in an academic hospital without a computerized physician order entry (CPOE) system. METHODS: This prospective observational study was conducted at a tertiary academic hospital between June 28 and August 31, 2017. It compared the proportion of medication prescription errors committed by surgery residents in their post-call (PC) and no-call (NC) states. A novel taxonomy was developed to classify medication prescription errors. RESULTS: Sixteen of twenty-one eligible residents (76%) participated in this study. Self-reported hours of sleep per night was significantly higher in the NC group compared to the PC group (6(4-8) vs 2(0-4) hours, P < 0.01). PC residents committed a significantly higher proportion of medication prescription errors versus NC residents (9.2% vs 3.2%; p=0.04). Decision-making and prescription-writing errors comprised 33% and 67% of errors, respectively. CONCLUSIONS: The post-call state in surgery residents is associated with a significantly higher proportion of medication prescription errors in a hospital without a CPOE system. Decision-making and prescription-writing errors could potentially be addressed by additional educational interventions.

Medication Prescribing Errors on a Surgery Service - Addressing the Gap with a Curriculum for Surgery Residents: A Prospective Observational Study.

OBJECTIVES: Educational interventions with proven effectiveness to reduce medication prescribing errors are currently lacking. Our objective was to implement and assess the effectiveness of a curriculum to reduce medication prescribing errors on a surgery service. METHODS: This was a prospective observational cohort study at a Canadian academic hospital without an electronic order entry system. A pharmacist-led medication prescribing curriculum for surgery residents was developed and implemented over 2 days (2 h/day) in July 2019. Thirteen (76%) out of 17 surgery residents contributed pre-implementation data, while 13 (81%) out of 16 surgery residents contributed post-implementation data. Medication prescribing errors were tracked for 12 months pre-implementation and 6 months post-implementation. Errors were classified as prescription writing (PW) or decision making (DM). RESULTS: There were a total of 1050 medication prescribing errors made in the pre-implementation period with 615 (59%) PW errors and 435 (41%) DM. There were a mean of 87.5 (SD = 14.6) total medication prescribing errors per month in the pre-implementation period with 51.3 (11.9) PW and 36.3 (6.0) DM errors. There were a total of 472 medication prescribing errors made in the post-implementation period with 260 (55%) PW and 212 (45%) DM errors. There were a mean of 78.7 (10.3) total medication prescribing errors per month in the post-implementation period with 43.3 (9.5) PW and 35.3 (4.2) DM errors. In the first quarter of the academic year, there were significantly fewer mean total errors per month post-implementation versus pre-implementation (77.7(12.7) versus 107.3(8.1); P = .035), with significantly fewer PW errors per month (40.7(13.2) versus 68.7(9.3); P = .046) and no difference in DM errors per month (37.0(2.0) versus 38.7(5.7);P = .671). There were no differences noted in the second quarter of the academic year. CONCLUSION: Medication prescribing errors occurred from PW and DM. Medication prescribing curriculum decreased PW errors; however, a continued education program is warranted as the effect diminished over time.

A Comparative Study of 2-Corner, 3-Corner, and 4-Corner Arthrodesis for Midcarpal Arthritis.

BACKGROUND: Four-corner fusion (4CF) is a common treatment for midcarpal arthritis; however, alternatives including 2-corner fusion (2CF) and 3-corner fusion (3CF) have been described. Limited literature suggests 2CF and 3CF may improve range of motion but have higher complication rates. Our objective is to compare function and patient-reported outcomes following 4CF, 3CF, and 2CF at our institution. METHODS: Adult patients undergoing 4CF, 3CF, and 2CF from 2011 to 2021 who attended at least one follow-up were included. Four-corner fusion patients were compared with those who underwent either 3CF or 2CF using staple fixation. Outcomes include nonunion rate, reoperation rate, progression to wrist fusion, range of motion, and patient-reported pain, satisfaction, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. RESULTS: A total of 58 patients met inclusion criteria. There were 49 4CF and 9 2CF or 3CF patients. Nonunion rates, progression to wrist fusion, and repeat surgery for any indication were not significantly different among groups. Range of motion (flexion-extension, radial-ulnar deviation) and grip strength at postoperative visits were not significantly different. Significantly more 4CF patients required bone grafting. Pain, overall satisfaction, and DASH scores were similar. CONCLUSIONS: Although prior studies suggest increased risk of nonunion and hardware migration after 2CF/3CF, we did not observe higher complication rates compared with 4CF. Range of motion, strength, and patient-reported outcomes were similar. While 4CF is traditionally the procedure of choice for midcarpal fusion, we found that when using a staple fixation technique, 2CF and 3CF have comparable clinical and patient-reported outcomes yet decrease the need for autologous bone grafting.

Oxandrolone in the Treatment of Burn Injuries: A Systematic Review and Meta-analysis.

Severe burns induce a profound hypermetabolic response, leading to a prolonged state of catabolism associated with organ dysfunction and delay of wound healing. Oxandrolone, a synthetic testosterone analog, may alleviate the hypermetabolic catabolic state thereby decreasing associated morbidity. However, current literature has reported mixed outcomes on complications following Oxandrolone use, specifically liver and lung function. We conducted an updated systematic review and meta-analysis studying the effects of Oxandrolone on mortality, length of hospital stay, progressive liver dysfunction, and nine secondary outcomes. We searched Pubmed, EMBASE, Web of Science, CINAHL, and Cochrane Databases of Systematic Reviews and Randomized Controlled Trials. Thirty-one randomized control trials and observational studies were included. Basic science and animal studies were excluded. Only studies comparing Oxandrolone to standard of care, or placebo, were included. Oxandrolone did not affect rates of mortality (relative risk [RR]: 0.72; 95% confidence interval [CI]: 0.47 to 1.08; P = .11) or progressive liver dysfunction (RR: 1.04; 95% CI: 0.59 to 1.85; P = .88), but did decrease length of stay in hospital. Oxandrolone significantly increased weight regain, bone mineral density, percent lean body mass, and decreased wound healing time for donor graft sites. Oxandrolone did not change the incidence of transient liver dysfunction or mechanical ventilation requirements. There is evidence to suggest that Oxandrolone is a beneficial adjunct to the acute care of burn patients; shortening hospital stays and improving several growth and wound healing parameters. It does not appear that Oxandrolone increases the risk of progressive or transient liver injury, although monitoring liver enzymes is recommended.

Scientific Impact and Clinical Influence: Identifying Landmark Studies in Burns.

Although many reviews describe significant advances in burn care, no studies have yet examined why these papers had such profound impact. Our objective was to identify the most highly cited, as well as the most clinically influential studies in burns, and describe their characteristics, to inform future research in the field. Web of Science was searched using keywords related to burns to identify the 100 most-cited burns papers. Study design, year and journal of publication, and subject of the paper were recorded. A mixed-methods approach was used to identify papers in burn research leading to change in clinical practice. Characteristics of these papers were compared with identify any factors predictive of future citations or clinical influence. The 100 highly cited papers were cited between 159 and 907 times. There was no correlation between total citations and journal impact factor, year of publication, or subject area. Level of evidence did not predict future citations or influence, but may be influenced by evolving research standards. Of 23 clinically influential studies, 6 were not among 100 most-cited. Using papers only from the 100 most-cited list was not sufficient to identify leading researchers in burns. Citation analysis is a beneficial, however not alone sufficient to identify landmark papers, particularly for multidisciplinary fields such as burns.

Surgery Tutor for Computational Assessment of Technical Proficiency in Soft-Tissue Tumor Resection in a Simulated Setting.

BACKGROUND: In competency-based medical education, progression between milestones requires reliable and valid methods of assessment. Surgery Tutor is an open-source motion tracking platform developed to objectively assess technical proficiency during open soft-tissue tumor resections in a simulated setting. The objective of our study was to provide evidence in support of construct validity of the scores obtained by Surgery Tutor. We hypothesized that Surgery Tutor would discriminate between novice, intermediate, and experienced operators. METHODS: Thirty participants were assigned to novice, intermediate, or experienced groups, based on the number of prior soft-tissue resections performed. Each participant resected 2 palpable and 2 nonpalpable lesions from a soft-tissue phantom. Surgery Tutor was used to track hand and instrument motions, number of tumor breaches, and time to perform each resection. Mass of excised specimens and margin status were also recorded. RESULTS: Surgery Tutor scores demonstrated "moderate" to "good" internal structure (test-retest reliability) for novice, intermediate, and experienced groups (interclass correlation coefficient = 0.596, 0.569, 0.737; p < 0.001). Evidence in support of construct validity (consequences) was demonstrated by comparing scores of novice, intermediate, and experienced participantsfor number of hand and instrument motions (690 ± 190, 597 ± 169, 469 ± 110; p < 0.001), number of tumor breaches (29 ± 34, 16 ± 11, 9 ± 6; p < 0.001), time per resection (677 ± 331 seconds, 561 ± 210 seconds, 449 ± 148 seconds; p < 0.001), mass of completely excised specimens (22 ± 7g, 21 ± 11g, 17 ± 6 g; p = 0.035), and rate of positive margin (68%, 50%, 28%; p < 0.001). There was "strong" and "moderate" relationships between motion scores and Objective Structured Assessment of Technical Skill scores, and time per resection and Objective Structured Assessment of Technical Skill scores respectively (r = -0.60, p < 0.001; r = -0.54, p < 0.001). CONCLUSION: Surgery Tutor scores demonstrate evidenceof construct validity with regards to good internal structure, consequences, and relationship to other variables in the assessment of technical proficiency duringopen soft-tissue tumor resections in a simulated setting. Utilization of Surgery Tutor can provide formative feedback and objective assessment of surgical proficiency in a simulated setting.