An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

OBJECTIVE: To investigate the nature of process failures in postoperative care, to assess their frequency and preventability, and to explore their relationship to adverse events. BACKGROUND: Adverse events are common and are frequently caused by failures in the process of care. These processes are often evaluated independently using clinical audit. There is little understanding of process failures in terms of their overall frequency, relative risk, and cumulative effect on the surgical patient. METHODS: Patients were observed daily from the first postoperative day until discharge by an independent surgeon. Field notes on the circumstances surrounding any nonroutine or atypical event were recorded. Field notes were assessed by 2 surgeons to identify failures in the process of care. Preventability, the degree of harm caused to the patient, and the underlying etiology of process failures were evaluated by 2 independent surgeons. RESULTS: Fifty patients undergoing major elective general surgery were observed for a total of 659 days of postoperative care. A total of 256 process failures were identified, of which 85% were preventable and 51% directly led to patient harm. Process failures occurred in all aspects of care, the most frequent being medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. Process failures accounted for 57% of all preventable adverse events. Communication failures and delays were the main etiologies, leading to 54% of process failures. CONCLUSIONS: Process failures are common in postoperative care, are highly preventable, and frequently cause harm to patients. Interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce hospital stay.

Training faculty in nontechnical skill assessment: national guidelines on program requirements.

OBJECTIVE: To develop guidelines for a faculty training program in nontechnical skill assessment in surgery. BACKGROUND: Nontechnical skills in the operating room are critical for patient safety. The successful integration of these skills into workplace-based assessment is dependent upon the availability of faculty who are able to teach and assess them. At present, no guidelines exist regarding the training requirements for such faculty in surgical contexts. METHODS: The development of the guidelines was carried out in several stages: stage 1-a detailed literature review on current training for nontechnical skill assessors; stage 2-semistructured interviews with a multidisciplinary panel (consisting of clinicians and psychologists/human factors specialists) of experts in surgical nontechnical skills; and stage 3-interview findings fed into an Expert Consensus Panel (ECP) Delphi approach to establish consensus regarding training requirements for faculty assessing nontechnical skills in surgery. RESULTS: The ECP agreed that training in nontechnical skill assessment should be delivered by a multidisciplinary team consisting of clinicians and psychologists/human factors specialists. The ECP reached consensus regarding who should be targeted to be trained as faculty (including proficiency and revalidation requirements). Consensus was reached on 7 essential training program content elements (including training in providing feedback/debriefing) and 8 essential methods of evaluating the effectiveness of a "train-the-trainers" program. CONCLUSIONS: This study provides evidence-based guidelines that can be used to guide the development and evaluation of programs to educate faculty in the training and assessment of nontechnical skills. Uptake of these guidelines could accelerate the development of surgical expertise required for safe and high-quality patient care.

A systematic review regarding the feasibility and safety of endoscopic full thickness resection (EFTR) for colonic lesions.

PURPOSE: This review summarizes the published methods of colonic EFTR, examining data on feasibility and safety. Due to the introduction of bowel cancer screening programs, there is an increasing incidence of complex colonic polyps and early colonic cancer that requires segmental colectomy. Traditional radical surgery is associated with significant morbidity, and there is a need for alternative treatments. METHODS: Systematic literature search identified articles describing EFTR techniques of colon, published between 1990 and 2012. Complication rates, anastomotic bursting pressures, procedure duration, specimen size and quality, and postmortem findings were analyzed. RESULTS: Five research groups reported four EFTR techniques using endoscopic stapling devices, T-tags, compression closure, or laparoscopic assistance for defect closure before or after specimen resection. A total of 113 procedures were performed in 99 porcine models, with an overall success rate of 89 and 4 % mortality. The intraoperative complication rate was 22 % (0-67 %). Post-resection closure methods more commonly resulted in failure to close the defect (5-55 %) and a high incidence of abnormal findings at postmortem examination (84 %). Significant heterogeneity was observed in procedure duration (median or mean 3-233 min) and size of the excised specimen (median or mean 1.7-3.6 cm). Anastomotic bursting pressures and specimen quality were poorly documented. CONCLUSIONS: The technique of EFTR is developing, but the inability to close the resection defect reliably is a major obstacle. The review highlights the challenges that need to be addressed in future preclinical studies.

Reliability in the process of care during emergency general surgical admission: A prospective cohort study.

INTRODUCTION: Emergency general surgery (EGS) is responsible for 80-90% of surgical in-hospital deaths and the early management of these unwell patients is critical to improving outcomes. Unfortunately care for EGS patients is often fragmented and important care processes are frequently omitted. METHODS: This study aimed to define a group of important processes during EGS admission and assess their reliability. Literature review and semi-structured interviews were used to define a draft list of processes, which was refined and validated using the Delphi consensus methodology. A prospective cohort study of the 22 included processes was performed in 315 patients across 5 acute hospitals. RESULTS: Prospective study of the 22 selected processes demonstrated omission of 1130/5668 (19.9%) processes. Only 6 (1.9%) patients had all relevant processes performed correctly. Administration of oxygen to hypoxic patients (82/129, 64%), consultant review (202/313, 65%) and administration of antibiotics within 3 h for patients with severe sepsis (41/60, 68%) were performed particularly poorly. There were significant differences in the mean number of omissions per patient between hospitals ( ANOVA: F = 11.008, p < 0.001) and this was strongly correlated with hospitals' median length of stay (Spearman's rho = 0.975, p = 0.005). CONCLUSIONS: Reliability of admissions processes in this study was poor, with significant variability between hospitals. It is likely that improvements in process reliability would enhance EGS patients' outcomes. This will require engagement of the entire surgical team and the implementation of multiple interventions to improve the effectiveness of the admission phase of care.

An observational study of teamwork skills in shift handover.

BACKGROUND: Clinical handover (handoff, sign out) is frequently implicated as a cause of adverse events in hospitalised patients. Complex social interactions such as handover are subject to the teamwork skills of the participants and there is increasing evidence that the quality of teamwork in handover affects outcome. Teamwork skills have been assessed in one-to-one handovers but the applicability of these measurement tools to healthcare team shift handovers remains unproven. This study aimed to assess the feasibility of measurement of teamwork skills in shift handover and the applicability of adapted teamwork skills rating scales to a shift handover environment. METHODS: Morning surgical shift handovers were assessed for completeness of information transfer, duration, interruptions and handover attendance. Handover teamwork skills were evaluated using two validated rating scales, adapted from one-to-one handovers and intra-operative teamwork skill measurement. RESULTS: 50 handovers, including 306 patients were observed. Communication checklist completion was 97% but the quality of teamwork skills varied widely between handovers. There was very good concurrent validity between the two teamwork skill rating scales (Spearman's rho = 0.67, p < 0.001). There was no significant correlation between content completion, duration, interruptions or attendance and teamwork skill ratings. CONCLUSIONS: Teamwork skills vary widely between handovers and can be consistently scored using both rating scales. It is feasible to use adapted teamwork skill rating scales in shift handover and they appear to measure different constructs to traditional handover measures such as interruptions and communication checklist completion. The assessment of teamwork skills is a necessary complement to the assessment of completeness of information transfer when evaluating the overall quality of handover.

Laparoscopic revision of failed antireflux surgery: a systematic review.

BACKGROUND: Laparoscopic antireflux surgery is an accepted treatment for persistent gastroesophageal reflux but about 4% of patients will eventually require revision surgery. METHODS: We searched The Cochrane Collaboration, Medline, and EMBASE databases, augmented by Google Scholar and PubMed related articles from January 1, 1990, to November 22, 2010. Twenty studies met the inclusion criteria, reporting on 930 surgeries. RESULTS: The mean surgical duration was 166 minutes and conversion to open revision fundoplication was required in 7% of cases. Complications were reported in 14% of cases and the mean length of stay varied between 1.2 and 6 days. A good to excellent result was reported for 84% of surgeries and 5% of patients required a further revisional procedure. CONCLUSIONS: Laparoscopic revision antireflux surgery appears to be feasible and safe, but subject to somewhat greater risk of conversion, higher morbidity, longer hospital stay, and poorer outcomes than primary laparoscopic fundoplication.