[NRFit: A new standard to prevent wrong-route medication errors]. / NRFit : une nouvelle norme de connexion pour prévenir les erreurs médicamenteuses concernant les voies d'administration.

Wrong route medication errors due to tubing misconnections can lead to serious adverse events, especially when they concern the neuraxial and perineural routes. It has been favoured by the use of the universal Luer connector for medical devices with a risk of confusion with the intravenous route. The prevention of these errors is based on passive measures such as using specific small-bore connectors, and active measures such as reading Specific labelling which must be systematically affixed to the routes. NRFit connectors are a type of small-bore connector specifically intended for neuraxial and perineural applications. They are based on the International Organization for Standardization (ISO) standard 80369-6. They are physically incompatible with other small-bore connectors, like the Luer connectors used for intra-venous and enteral medication administration, and thus help prevent inadvertent misconnections. While some countries have already implemented this standard, France is behind schedule in implementing the NRFit connectors due to the absence of strong recommendations or obligations from the authorities. However, NRFit connectors represents real progress for the prevention of medication errors.

[Compensation of unforeseeable medical complications following cosmetic surgery finally made possible by ONIAM]. / L'indemnisation enfin possible par l'ONIAM des aléas thérapeutiques après un acte de chirurgie esthétique.

In the absence of any proven medical fault by a plastic surgeon, the patient could not obtain compensation through national solidarity (as stipulated by the Law of March 4th 2002). Indeed ONIAM (France's National Office for Medical Accidents' Compensation) has always rejected any claims on the grounds that cosmetic surgery differs from medical care. Through its judgment of February 5th 2014, France's final Court of Appeals settled the question and considered cosmetic surgery as medical care; in case of serious injuries following unforeseeable medical complications, the patient may be compensated by ONIAM, as with any other medical act. This jurisprudence will certainly result in medical liability insurers be no longer those only responsible for compensation of injuries following cosmetic surgery. Plastic surgeons' insurance premiums should logically become cheaper.

[Responsibility due to medication errors in France: a study based on SHAM insurance data]. / Responsabilité liée aux erreurs médicamenteuses : données SHAM.

PURPOSE: The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications. METHODS: The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010). RESULTS: Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy. CONCLUSION: The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management.

[Faulty implants: the court of appeal has ruled surgeon's responsibility]. / Prothèse défectueuse : la responsabilité du chirurgien écartée par la Cour de cassation.

It is in this atmosphere fuelled by the recent scandal of the PIP implants that the final court of appeal has given a judgment on July 12, 2012 which reorients the debate. While patients seeked a shared responsibility between the provider of the implants and the surgeon, in this case of faulty testicular implants, the final court of appeal just ruled out the responsibility of the surgeon. But this jurisprudence can only be applied to private law, i.e. for private healthcare whereas lawsuits filed against public hospitals depend on a different legal liability system.

Enhanced recovery after elective surgery. A revolution that reduces post-operative morbidity and mortality.

Enhanced recovery (ER) after elective surgery has been a real revolution in peri-operative care. This concept, initially called "fast-track surgery", has evolved into "enhanced recovery or rehabilitation" (ER), which highlights the improvement of post-operative procedures rather than the simple shortening of hospital stay. The main benefit of ER is the reduction of the impact of surgical trauma with an attendant reduction of post-operative complications. This result has been demonstrated based on a good level of evidence for multiple surgical specialties. Mild complications are the most impacted by this program. The reduction in the duration of stay is thus the result of the improvement in post-operative care. This update illustrates the benefits of ER by taking three examples of elective surgery in three major surgical specialties: colorectal surgery, orthopedics and gynecological surgery. The post-operative complications impacted by ER programs and the mechanisms of this effect are also discussed.

Risk management in outpatient surgery.

Outpatient surgery has become a national policy priority set by health care authorities (targets for more than 70% of outpatient procedures by 2022), making ambulatory hospitalization the new standard of care. This practice introduces new risks along the patient's course. Even though these risks are low and although the literature and data from insurance databases is reassuring, the risks in outpatient surgery remain poorly understood. Risks can be organizational in view of the many stages of the patient journey that must be formalized-medical, anesthetic or surgical-in view of planned discharge the same evening as the procedure, and medico-legal because of the importance of the discharge authorization and the information provided to the patient. A risk management approach (a priori or a posteriori) has become a mandatory part of a policy of continuous quality improvement and safety of care. The coordination of all the team members (surgeon, anesthesiologist, nursing and administrative staff and the patient's accompanying person) as well as the patient's active participation are essential to minimize risks and prevent complications.

Serious adverse events and deaths linked to poor ventilator use: A report of four closed claims.

Through this series of four closed claims, we highlight examples of accidents stemming from poor ventilator use. We then review the main issues in this regard as reported in the literature and by learned societies. This case series has led us to emphasise the need for safety procedures involving systematic checks prior to use, declaration and analysis of the risk, as well as feedback and teaching regarding ventilation systems.

A ten-year analysis of the reasons for death following ambulatory surgery: Nine closed claims declared to the SHAM insurance.

INTRODUCTION: The constant development of ambulatory surgery (AS) raises the problem of monitoring patients after discharge and the risk of death in the case of delays in the management of a serious complication. PATIENTS AND METHODS: The aim of this retrospective study was to describe the deaths observed within the 30-day period following AS declared to the SHAM insurance (Société hospitalière d'assurance mutuelle) over the last 10 years. RESULTS: During the study period 33,962 claims were surgery-related and 11 were for deaths after AS. Two of the death claims were excluded from our study because they occurred after the first month. The surgeries concerned were tonsilectomy (3), cataract (2), inguinal hernia (2), varicose vein stripping (1) and laparoscopy (1). Death occurred on average 5.4 days after the AS, in intensive care (3), during hospitalisation (2), with emergency medical services (1), in an emergency department (1) or at home (2). Anaesthesia was directly implicated in 3 cases: anaphylactic shock (Diamox), pneumoperitoneum (gastric swelling) and hemoperitoneum (mismanagement of anticoagulants). 1 case was due to a pulmonary embolism and 5 to a surgical cause. DISCUSSION-CONCLUSION: There was only one case where the complication was aggravated due to the delay of care provision and this was because of a lack of information on the complications requiring an emergency return (abdominal pain after laparoscopy). In all the other cases, death would also probably have occurred during conventional hospitalisation, either because it was unavoidable or because the patient was too far from the surgery.

Are enhanced recovery programs in colorectal surgery feasible and useful in the elderly? A systematic review of the literature.

INTRODUCTION: Enhanced recovery programs (ERP) are no longer questionable in the management of patients undergoing surgery. However, there is some doubt as to their feasibility and efficacy in the elderly. Our goal was to systematically review the evidence-based literature concerning the feasibility of ERP in elderly patients undergoing colorectal surgery. MATERIAL AND METHODS: The PubMed and Cochrane Database for systematic reviews as well as the "grey" literature between 2000 and 2015 were sought. Articles were selected if they compared ERP in elderly patients to ERP in young patients (feasibility) or compared ERP to traditional post-operative management in the elderly (efficacy). RESULTS: Sixteen articles were identified according to the inclusion criteria. All showed that an ERP was feasible in the elderly although post-operative morbidity was higher compared to younger patients. Compared to traditional management, ERP was effective since it decreased (as in the young) the overall rate of complications and thus the duration of hospital stay. There were not enough data on the degree of implementation of ERP and the medico-economic aspects to come to any formal conclusions. CONCLUSION: This comprehensive systematic review of the literature showed that ERP was feasible and effective in the elderly undergoing colorectal surgery. Protocols should be adapted to the particular aspects of this population. Future research should target pre-operative evaluation and the place of pre-habilitation in geriatric ERP.

[Closed claims in obstetrics: A study based on French Sham insurance data]. / Sinistralité en obstétrique dans les hôpitaux publics français: données Sham.

OBJECTIVE: The aim of this study was to analyze the medicolegal claims related to obstetrics in French hospitals. MATERIAL AND METHODS: We did retrospective study on insurance claims provided by Sham insurances and which has been settled by a court over a 3-year period (2004-2006). RESULTS: We analyzed 66 closed claims that occurred between 1983 and 2005 in French hospitals (54 general hospitals and 12 academic). The average time between the declaration of the claim and the court conviction was 6 years. The average amount of compensation per claim was 500,000 €. The damage occurred during vaginal delivery (n=44), planned (n=5) or unplanned (n=4) cesarean. The more often claims are fetal asphyxia (n=24) or shoulder dystocia (n=8). The consequences are very important: cerebral palsy (16), death of the newborn (12), death of the mother (2) or brachial plexus injuries (6). CONCLUSION: The causes identified by the expert are always multifactorial with generally a misdiagnosis (n=27), a decision making error (n=36), a care error by the midwife (n=21) and/or a delay in medical care (n=13). These data should help strengthen the quality approach in obstetrics.

[Epidemiology of the medico-legal risk associated with the practice of ambulatory surgery in France: a study based on insurance data]. / Épidémiologie du risque médico-légal lié à la pratique de la chirurgie ambulatoire en France: données SHAM.

UNLABELLED: The medico-legal risk specifically associated with the practice of ambulatory surgery is still not well studied. SHAM insurances are the biggest French provider of medical liability insurances. The study of the insurance claims provided by this insurer is therefore a relevant source of data on the complications related to ambulatory surgery. OBJECTIVE: The aim of this study was to compare the claim rate related to ambulatory surgery with non-ambulatory surgery. STUDY DESIGN: We did a retrospective study on insurance claims provided by SHAM insurances between 2007 and 2011 to compare the claim rate related to ambulatory surgery with non-ambulatory surgery. MATERIALS AND METHODS: We searched the files in the SHAM database, and then analyzed them. RESULTS: On the study period, out of a total of 29565 registered claims, 467 (1.6%) originated from ambulatory surgery. On the total of 29,098 registered claims for non-ambulatory surgery, 2151 (7.4%) led to a condemnation whereas the rate was 7% (33 out of 467 claims) for ambulatory surgery. The condemnations linked to ambulatory surgery amounted to 1.5% of the total (33 out of 2184), for a cost of 1.7 M€ (versus 400,3 M€ for non-ambulatory surgery). The average cost of a compensation is therefore 50,500 € for ambulatory surgery and 186,000 € for non-ambulatory surgery. The medical specialties concerned are primarily ophthalmology, abdominal and orthopedics surgery. The main identified causes were medical errors (n=16) and nosocomial infections (n=13). CONCLUSIONS: The claim rate in ambulatory surgery is proportionally less frequent with compensations three times less and were related to the most frequent type of surgery done in ambulatory settings. These data should help strengthen quality approach in ambulatory surgery.

[Peripheral nerve block in orthopaedic surgery: multicentric evaluation of practicing professionals and impact on the activity of the recovery room]. / ALR périphérique en orthopédie: évaluation multicentrique des pratiques et impact sur l'activité de la SSPI.

OBJECTIVES: Since the last national survey on evaluation of professional practice in France, many peripheral nerve blocks techniques were developed. The aim of this study was to assess the place of such techniques and their impact on the stay in recovery room after orthopaedic surgery. STUDY DESIGN: Prospective, multicentric study. PATIENTS AND METHODS: Consecutive patients receiving a regional anaesthetic technique for orthopaedic surgery over a 15-day period were included in this multicenter study (four private clinics, two non-university and three university hospitals). Characteristics of blocks, duration of stay and activity of nurses in post-anaesthetic care unit (PACU) were recorded for each patient. RESULTS: A total of 289 blocks performed in 283 patients were analyzed. A regional anaesthetic technique was performed alone or associated with a light sedation (58 and 8% respectively) or with a general anaesthesia (44%). A continuous peripheral nerve block (mainly for femoral and iliofascial blocks) was performed in 25% of patients, mostly in university hospital and private clinics (35 and 26% respectively), but only in 3% of cases in non-university hospital. Mean duration of PACU stay was 64+/-67 minutes. This time was longer when regional anaesthesia was associated to or performed after general anaesthesia. Workload of nurses was a simple supervision in 47% of the cases (in 61% of patients receiving regional anaesthesia alone vs 21% in those with general anaesthesia, p<0.05). CONCLUSION: This survey confirms that peripheral nerve block became widely used in orthopaedic surgery. This decreases the medical workload in PACU, especially for distal upper limb surgery. Regional anaesthetic techniques must be well taught during formation cursus of residents.

Improving source reconstructions by combining bioelectric and biomagnetic data.

OBJECTIVES: A framework for combining bioelectric and biomagnetic data is presented. The data are transformed to signal-to-noise ratios and reconstruction algorithms utilizing a new regularization approach are introduced. METHODS: Extensive simulations are carried out for 19 different EEG and MEG montages with radial and tangential test dipoles at different eccentricities and noise levels. The methods are verified by real SEP/SEF measurements. A common realistic volume conductor is used and the less well known in vivo conductivities are matched by calibration to the magnetic data. Single equivalent dipole fits as well as spatio-temporal source models are presented for single and combined modality evaluations and overlaid to anatomic MR images. RESULTS: Normalized sensitivity and dipole resolution profiles of the different EEG/MEG acquisition systems are derived from the simulated data. The methods and simulations are verified by simultaneously measured somatosensory data. CONCLUSIONS: Superior spatial resolution of the combined data studies is revealed, which is due to the complementary nature of both modalities and the increased number of sensors. A better understanding of the underlying neuronal processes can be achieved, since an improved differentiation between quasi-tangential and quasi-radial sources is possible.