System Factors Affecting Patient Safety in the OR: An Analysis of Safety Threats and Resiliency.

OBJECTIVE: The objective of this study is to determine the characteristics and frequency of intraoperative safety threats and resilience supports using a human factors measurement tool. BACKGROUND: Human factors analysis can provide insight into how system elements contribute to intraoperative adverse events. Empiric evidence on safety threats and resilience in surgical practice is lacking. METHODS: A cross-sectional study of 24 patients undergoing elective laparoscopic general surgery at a single center in the Netherlands from May to November, 2017 was conducted. Video, audio, and patient physiologic data from all included procedures were obtained through a multichannel synchronized recording device. Trained analysts reviewed the recordings and coded safety threats and resilience supports. The codes were categorized into 1 of 6 categories (person, task, tools and technology, physical environment, organization, and external environment). RESULTS: A median of 14 safety threats [interquartile range (IQR) 11-16] and 12 resilience supports (IQR 11-16) were identified per case. Most safety threat codes (median 9, IQR 7-12) and resilience support codes (median 10, IQR 7-12) were classified in the person category. The organization category contained a median of 2 (IQR 1-2) safety threat codes and 2 (IQR 2-3) resilience support codes per case. The tools and technology category contributed a small number of safety threats (median 1 per case, IQR 0-1), but rarely provided resilience support. CONCLUSIONS: Through a detailed human factors analysis of elective laparoscopic general surgery cases, this study provided a quantitative analysis of the existing safety threats and resilience supports in a modern endoscopic operating room.

Underreporting of Veress Needle Injuries: Comparing Direct Observation and Chart Review Methods.

BACKGROUND: Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events. MATERIALS AND METHODS: Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries. RESULTS: Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts. CONCLUSIONS: Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review.

Management of non-union of rib fractures secondary to trauma: A scoping review.

OBJECTIVE: Rib fracture non-union is an uncommon complication of traumatic rib fractures. Our objective was to perform a scoping review of the literature for the management of rib fracture non-union. This included analysis of the variations in surgical technique, complications experienced, and reported outcomes. METHODS: We conducted a scoping review and searched databases (MEDLINE, CINAHL, and Embase). We performed abstract and full-text screening, and abstracted data related to pre-operative assessment, surgical technique, complications, and reported outcome measures. RESULTS: We included 29 articles of which 19 were case reports and 10 were case series. The data quality was generally heterogeneous. The studies included 229 patients and the commonest symptoms of rib fracture non-union included chest pain, clicking, dyspnea and deformities. The patients underwent surgical management of rib fracture non-union (excluding first rib fractures) using various techniques. The majority used surgical stabilization of rib fracture with or without a graft. The reported outcomes were inconsistent between studies, but showed high rates of union (>94 %), reduction in reported VAS scores, and improved return to work when included. Implant failure occurred in 10 % of the 229 total patients reported in our studies, the re-operation rate was 13 %, and the overall complication rate was 27 %. CONCLUSION: Surgical management of rib fracture non-union often involving locking plates and screws with or without a graft has been shown in several case reports and series as an effective treatment with acceptable implant failure and complication rates. Surgical management is therefore a viable option for symptomatic patients. Further research is required to determine optimal management strategies that further reduce surgical complications for these patients.