Intraoperative adverse events among surgeons in Singapore: a multicentre cross-sectional study on impact and support.

BACKGROUND: It is known that many surgeons encounter intraoperative adverse events which can result in Second Victim Syndrome (SVS), with significant detriment to their emotional and physical health. There is, however, a paucity of Asian studies in this space. The present study thus aimed to explore the degree to which the experience of an adverse event is common among surgeons in Singapore, as well as its impact, and factors affecting their responses and perceived support systems. METHODS: A self-administered survey was sent to surgeons at four large tertiary hospitals. The 42-item questionnaire used a systematic closed and open approach, to assess: Personal experience with intraoperative adverse events, emotional, psychological and physical impact of these events and perceived support systems. RESULTS: The response rate was 57.5% (n = 196). Most respondents were male (54.8%), between 35 and 44 years old, and holding the senior consultant position. In the past 12 months alone, 68.9% recalled an adverse event. The emotional impact was significant, including sadness (63.1%), guilt (53.1%) and anxiety (45.4%). Speaking to colleagues was the most helpful support source (66.7%) and almost all surgeons did not receive counselling (93.3%), with the majority deeming it unnecessary (72.2%). Notably, 68.1% of the surgeons had positive takeaways, gaining new insight and improving vigilance towards errors. Both gender and surgeon experience did not affect the likelihood of errors and emotional impact, but more experienced surgeons were less likely to have positive takeaways (p = 0.035). Individuals may become advocates for patient safety, while simultaneously championing the cause of psychological support for others. CONCLUSIONS: Intraoperative adverse events are prevalent and its emotional impact is significant, regardless of the surgeon's experience or gender. While colleagues and peer discussions are a pillar of support, healthcare institutions should do more to address the impact and ensuing consequences.

The Safety of Inpatient Health Care.

BACKGROUND: Adverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted. METHODS: We conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events. RESULTS: In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care-associated infections (11.9%). CONCLUSIONS: Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.).

Retratamientos endodónticos: una realidad que preocupa / Endodontic retreatment: a worrying reality

Las evaluaciones radiográficas de tratamientos endodón- ticos realizadas por graduados muestran un alto porcentaje de procedimientos incorrectos. Esta circunstancia lleva a la rea- lización de un elevado número de retratamientos ortógrados y retrógrados, con los inconvenientes y desventajas que conlle- va recurrir a una reintervención endodóntica. Es responsabili- dad de los profesionales, docentes y autoridades universitarias y gubernamentales revertir esta situación que afecta a la salud bucal de la sociedad. En el presente editorial se proponen di- ferentes alternativas para intentar modificar este preocupante panorama (AU)

Radiographic evaluations of endodontic treatments per- formed by graduates show a high percentage of incorrect procedures. This circumstance leads to the performance of a high number of orthograde and retrograde retreatments, with the inconveniences and disadvantages that entails resorting to an endodontic reintervention. It is the responsibility of pro- fessionals, teachers, university and government authorities to reverse this situation that affects the oral health of society. In this editorial, different alternatives are proposed to try to modify this worrying outlook (AU)

Accuracy of Pathology Reports on Neck Dissection Specimens: A Retrospective Case Series Study.

BACKGROUND: Accuracy of the number and location of pathological lymph nodes (LNs) in the pathology report of a neck dissection (ND) is of vital importance. OBJECTIVES: To quantify the error rate in reporting the location and number of pathologic LNs in ND specimens. METHODS: All patients who had undergone a formal ND that included at least neck level 1 for a clinical N1 disease between January 2010 and December 2017 were included in the study. The error rate of the pathology reports was determined by various means: comparing preoperative imaging and pathological report, reporting a disproportionate LN distribution between the different neck levels, and determining an erroneous location of the submandibular gland (SMG) in the pathology report. Since the SMG must be anatomically located in neck level 1, any mistake in reporting it was considered a categorical error. RESULTS: A total of 227 NDs met the inclusion criteria and were included in the study. The study included 128 patients who had undergone a dissection at levels 1-3, 68 at levels 1-4, and 31 at levels 1-5. The best Kappa score for correlation between preoperative imaging and final pathology was 0.50. There were nine cases (3.9%) of a disproportionate LN distribution in the various levels. The SMG was inaccurately reported outside neck level 1 in 17 cases (7.5%). CONCLUSIONS: At least 7.5% of ND reports were inaccurate in this investigation. The treating physician should be alert to red flags in the pathological report.

Characteristics of Disease-Specific and Generic Diagnostic Pitfalls: A Qualitative Study.

Importance: Progress in understanding and preventing diagnostic errors has been modest. New approaches are needed to help clinicians anticipate and prevent such errors. Delineating recurring diagnostic pitfalls holds potential for conceptual and practical ways for improvement. Objectives: To develop the construct and collect examples of "diagnostic pitfalls," defined as clinical situations and scenarios vulnerable to errors that may lead to missed, delayed, or wrong diagnoses. Design, Setting, and Participants: This qualitative study used data from January 1, 2004, to December 31, 2016, from retrospective analysis of diagnosis-related patient safety incident reports, closed malpractice claims, and ambulatory morbidity and mortality conferences, as well as specialty focus groups. Data analyses were conducted between January 1, 2017, and December 31, 2019. Main Outcomes and Measures: From each data source, potential diagnostic error cases were identified, and the following information was extracted: erroneous and correct diagnoses, presenting signs and symptoms, and areas of breakdowns in the diagnostic process (using Diagnosis Error Evaluation and Research and Reliable Diagnosis Challenges taxonomies). From this compilation, examples were collected of disease-specific pitfalls; this list was used to conduct a qualitative analysis of emerging themes to derive a generic taxonomy of diagnostic pitfalls. Results: A total of 836 relevant cases were identified among 4325 patient safety incident reports, 403 closed malpractice claims, 24 ambulatory morbidity and mortality conferences, and 355 focus groups responses. From these, 661 disease-specific diagnostic pitfalls were identified. A qualitative review of these disease-specific pitfalls identified 21 generic diagnostic pitfalls categories, which included mistaking one disease for another disease (eg, aortic dissection is misdiagnosed as acute myocardial infarction), failure to appreciate test result limitations, and atypical disease presentations. Conclusions and Relevance: Recurring types of pitfalls were identified and collected from diagnostic error cases. Clinicians could benefit from knowledge of both disease-specific and generic cross-cutting pitfalls. Study findings can potentially inform educational and quality improvement efforts to anticipate and prevent future errors.

Compensated Patient Injuries in the Treatment of Abdominal Aortic and Iliac Artery Aneurysms in Finland: A Nationwide Patient Insurance Registry Study.

OBJECTIVES: Patient injury claims data and insurance records provide detailed information on patient injuries. This study aimed to identify the errors and adverse events that led to patient injuries in vascular surgery for the treatments of abdominal aortic aneurysms (AAA) and iliac artery aneurysms (IAA) in Finland. The study also assessed the severity and preventability of the injuries. MATERIALS AND METHODS: A retrospective analysis of Finnish Patient Insurance Centre's insurance charts of compensated patient injuries in the treatment of AAA and IAA. Records of all compensated patient injury claims involving AAA and IAA between 2004 and 2017 inclusive were reviewed. Contributing factors to injury were identified and classified. The injuries were assessed for their preventability by using the WHO Surgical Safety Checklist correctly. The degree of harm was graded by Clavien-Dindo classification. RESULTS: Twenty-six patient injury incidents were identified in the treatment of 23 patients. Typical injuries involved delays in diagnosis or treatment, errors in surgical technique or injuries to adjacent anatomic organs. Three (13.0%) patients died due to patient injury. Two deaths were caused by delays in diagnosis of ruptured abdominal aortic aneurysm (RAAA) and the third death was due to missed diagnosis of post-operative myocardial infarction. Retained foreign material caused injuries to two (8.7%) patients. One (4.3%) patient had a severe postoperative infection. Three (13.0%) patients experienced an injury to an adjacent organ. One patient had a bilateral and another a unilateral above-the-knee amputation due to patient injury. Three injuries were considered preventable. Most harms were grade IIIb Clavien-Dindo classification in which injured patients required a surgical intervention under general anesthesia. CONCLUSIONS: Compensated patient injuries involving the treatment of AAA and IAA are rare, but are often serious. Injuries were identified during all stages of care. Most injuries involved open surgical procedures.

The right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation: a prospective observational study.

Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound-guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One -hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J-tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real-time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J-tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J-tip to a correct position in the lower superior vena cava. All ultrasound-determined final guidewire J-tip positions were consistent with the central venous catheter tip positions on chest X-ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6-8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real-time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation.

Endodontic mishaps during root canal treatment performed by undergraduate dental students: An observational study.

ABSTRACT: Endodontic mishaps during root canal treatment (RCT) are considered to be one of the most commonly encountered errors, which affect the quality of treatment and may have dangerous health implications for patients.The present study was conducted to assess the frequency and types of endodontic mishaps in root canal-treated teeth performed by undergraduate dental students.A total 404 endodontically treated teeth were performed by undergraduate dental students of King Khalid University College of Dentistry, Abha, Kingdom of Saudi Arabia. The radiographs of the endodontically treated teeth were studied for a period of 6 months, and the related demographic data were collected from patient files.The most commonly identified mishaps were related to obturation, where the maximum number of cases (68.1%) had under-obturated root canals. More endodontic mishaps were performed by students in level 9 education. The upper left 2nd molar teeth had a higher frequency of mishaps, and molars were found to have more access-related mishaps. Lastly, access-related and instrument-related mishaps had a low frequency of occurrence.The majority of endodontic mishaps found in the study sample were related to root canal obturation. The undergraduate students at level 9 were less proficient in conducting RCTs with many endodontic mishaps when compared to the cases performed by students at higher levels. The study suggests relevant guidance for dental students while performing RCTs, especially during obturation of the root canals.

The relationship between health IT characteristics and organizational variables among German healthcare workers.

Health information technologies (HITs) are widely employed in healthcare and are supposed to improve quality of care and patient safety. However, so far, their implementation has shown mixed results, which might be explainable by understudied psychological factors of human-HIT interaction. Therefore, the present study investigates the association between the perception of HIT characteristics and psychological and organizational variables among 445 healthcare workers via a cross-sectional online survey in Germany. The proposed hypotheses were tested using structural equation modeling. The results showed that good HIT usability was associated with lower levels of techno-overload and lower IT-related strain. In turn, experiencing techno-overload and IT-related strain was associated with lower job satisfaction. An effective error management culture at the workplace was linked to higher job satisfaction and a slightly lower frequency of self-reported medical errors. About 69% of surveyed healthcare workers reported making errors less frequently than their colleagues, suggesting a bias in either the perception or reporting of errors. In conclusion, the study's findings indicate that ensuring high perceived usability when implementing HITs is crucial to avoiding frustration among healthcare workers and keeping them satisfied. Additionally healthcare facilities should invest in error management programs since error management culture is linked to other important organizational variables.

Factors Related to Serious Safety Events in a Children's Hospital Patient Safety Collaborative.

BACKGROUND AND OBJECTIVES: Serious safety events (SSEs) occur infrequently at individual hospitals, making it difficult to establish trends to improve patient care. Patient safety organizations, such as the Child Health Patient Safety Organization (CHILDPSO), can identify trends and support learning across children's hospitals. We aim to describe longitudinal trends in SSE rates among CHILDPSO member hospitals and describe their sources of harm. METHODS: SSEs from 44 children's hospitals were assigned severity and reported to CHILDPSO from January 1, 2015, to December 31, 2018. SSEs were classified into groups and subgroups based on analysis. Events were then tagged with up to 3 contributing factors. Subgroups with <5 events were excluded. RESULTS: There were 22.5 million adjusted patient days included. The 12-month rolling average SSE rate per 10 000 adjusted patient days decreased from 0.71 to 0.41 (P < .001). There were 830 SSEs reported to CHILDPSO. The median hospital volume of SSEs was 12 events (interquartile range: 6-23), or ∼3 SSEs per year. Of the 830 events, 21.0% were high severity (SSE 1-3) and approximately two-thirds (67.0%, n = 610) were patient care management events, including subgroups of missed, delayed, or wrong diagnosis or treatment; medication errors; and suboptimal care coordination. The most common contributing factor was lack of situational awareness (17.9%, n = 382), which contributed to 1 in 5 (20%) high-severity SSEs. CONCLUSIONS: Hospitals sharing SSE data through CHILDPSO have seen a decrease in SSEs. Patient care management was the most frequently seen. Future work should focus on investigation of contributing factors and risk mitigation strategies.

Wrong-Patient Orders in Obstetrics.

OBJECTIVE: To compare rates of wrong-patient orders among patients on obstetric units compared with reproductive-aged women admitted to medical-surgical units. METHODS: This was an observational study conducted in a large health system in New York between January 1, 2016, and December 31, 2018. The primary outcome was near-miss wrong-patient orders identified using the National Quality Forum-endorsed Wrong-Patient Retract-and-Reorder measure. All electronic orders placed for eligible patients during the study period were extracted retrospectively from the health system data warehouse, and the unit of analysis was the order session (consecutive orders placed by a single clinician for a patient within 60 minutes). Multilevel logistic regression models were used to estimate odds ratios (ORs) and 95% CIs comparing the probability of retract-and-reorder events in obstetric and medical-surgical units, overall, and in subgroups defined by clinician type and order timing. RESULTS: Overall, 1,329,463 order sessions were placed during the study period, including 676,643 obstetric order sessions (from 45,436 patients) and 652,820 medical-surgical order sessions (from 12,915 patients). The rate of 79.5 retract-and-reorder events per 100,000 order sessions in obstetric units was significantly higher than the rate in the general medical-surgical population of 42.3 per 100,000 order sessions (OR 1.98, 95% CI 1.64-2.39). The obstetric retract-and-reorder event rate was significantly higher for attending physicians and house staff compared with advanced practice clinicians. There were no significant differences in error rates between day and night shifts. CONCLUSION: Order errors occurred more frequently on obstetric units compared with medical-surgical units. Systems strategies shown to decrease these events in other high-risk specialties should be explored in obstetrics to render safer maternity care.

Incidence of missing pathology specimens in dermatology.

BACKGROUND: Occasionally specimen containers are received in the dermatopathology laboratory without an accompanying specimen. The consequences in this scenario can range from delay in care and inconvenience to patients to increased morbidity and even mortality. Data regarding incidence and associated characteristics of missing specimens are scant. METHODS: Over a 10-year period (7 January 2010 to 7 January 2020) all cases with a missing specimen in a single academic dermatopathology laboratory and a single dermatopathology practice embedded within a dermatology practice were reviewed. RESULTS: Out of 270,754 specimens received, 83 empty specimen containers were identified for an incidence of 0.031%. There were 14 (0.005%) cases in which patients had a separate procedure and a second container with both specimens in it accompanying the empty container. The most common missing specimen-generating procedures were shave biopsies (51%) with most common clinical diagnosis being unspecified (30%). The most common specimen location from the 97 total specimen bottles containing either zero or two specimens was head/neck (53%). Although no further procedures were performed after the specimen was lost for 48% of cases, re-biopsy occurred for 28%. CONCLUSIONS: Failure to insert specimens into the correct container is rare, but represents a potential significant negative event where vigilance and improvement is required.

Critical Care Nurses' Physical and Mental Health, Worksite Wellness Support, and Medical Errors.

BACKGROUND: Critical care nurses experience higher rates of mental distress and poor health than other nurses, adversely affecting health care quality and safety. It is not known, however, how critical care nurses' overall health affects the occurrence of medical errors. OBJECTIVE: To examine the associations among critical care nurses' physical and mental health, perception of workplace wellness support, and self-reported medical errors. METHODS: This survey-based study used a cross-sectional, descriptive correlational design. A random sample of 2500 members of the American Association of Critical-Care Nurses was recruited to participate in the study. The outcomes of interest were level of overall health, symptoms of depression and anxiety, stress, burnout, perceived worksite wellness support, and medical errors. RESULTS: A total of 771 critical care nurses participated in the study. Nurses in poor physical and mental health reported significantly more medical errors than nurses in better health (odds ratio [95% CI]: 1.31 [0.96-1.78] for physical health, 1.62 [1.17-2.29] for depressive symptoms). Nurses who perceived that their worksite was very supportive of their well-being were twice as likely to have better physical health (odds ratio [95% CI], 2.16 [1.33-3.52]; 55.8%). CONCLUSION: Hospital leaders and health care systems need to prioritize the health of their nurses by resolving system issues, building wellness cultures, and providing evidence-based wellness support and programming, which will ultimately increase the quality of patient care and reduce the incidence of preventable medical errors.

Rates of Serious Surgical Errors in California and Plans to Prevent Recurrence.

Importance: Despite widespread recognition and known harms, serious surgical errors, known as surgical never events, endure. The California Department of Public Health (CDPH) has developed an oversight system to capture never events and a platform for process improvement that has not yet been critically appraised. Objectives: To examine surgical never events occurring in hospitals in California and summarize recommendations to prevent future events. Design, Setting, and Participants: This cross-sectional study identified 386 CDPH hospital administrative penalty reports, of which 142 were ascribable to never events occurring during surgery. These never events were identified and summarized from January 1, 2007, to December 31, 2017. A directed qualitative approach was used to analyze CDPH-mandated corrective steps to reduce future errors in this multicenter study of all accredited hospitals in California. Inclusion of surgical never event records was based on definitions established by the US Department of Health and Human Services National Quality Forum. Data analysis was performed from January 1, 2019, to November 30, 2020. Exposures: Never events include death or disability of an American Society of Anesthesiologists class I patient, wrong site or wrong surgery, retained foreign objects, burns, equipment failure leading to intraoperative injury, nonapproved experimental procedures, insufficient surgeon presence or privileges, or fall from the operating room table. Main Outcomes and Measures: Incident rates, consequences, and improvement plans to prevent additional never events were outcomes of interest. Results: A total of 142 never events were reported to the CDPH (1 per 200 000 operations). Annual surgical volume for hospitals with events was 9203 vs 3251 cases for hospitals without events (P < .001). A total of 94 of 142 events (66.2%) were retained foreign objects ranging from Kocher clamps to drain sponges. Wrong site or patient surgery accounted for 22 events (15.5%), surgical burns for 11 (7.7%), and other for 15 (10.6%). Other included insufficient surgeon presence, equipment failure, or falls in the operating room. Improvement plans included 18 unique categories of recommendations from regulators, many focusing on proper use of checklists. Regulators mandated a mean (SD) of 13 (7) corrective actions in the improvement plans. Policy adherence monitoring (119 [90.2%]), revision of existing policy (84 [63.6%]), and education regarding policy (83 [62.9%]) were common action items, whereas disciplinary action toward staff was rare (11 [8.3%]). Conclusions and Relevance: Surgical never events are a rare issue in California. Numerous strategies have evolved to reduce errors, many involving the thorough and proper use of intraoperative checklists.

How can Never Event data be used to reflect or improve hospital safety performance?

The absolute number of Never Events is used by UK regulators to help assess hospital safety performance, without account of hospital workload. We applied funnel plots, as an established means of taking workload into account, to published Never Event data for 151 acute Trusts in NHS England, matched to finished consultant episodes for 3 years, 2017-2020. Trusts with excess event rates should have the most Never Events if absolute number is a valid way to judge performance. The absolute number of Never Events was correlated with workload (r2 = 0.51, p < 0.001), but the five Trusts above the upper 95% confidence limit did not have the highest number of Never Events. However, a limitation to interpretation was that the data were skewed; 12 out of 151 Trusts lay below the lower 95% limit. This skew probably arises because funnel plots pool all Never Events and workload data; whereas, ideally, different Never Events should use as denominator only the relevant workload actions that could cause them. We conclude that the manner in which Never Event data are currently used by regulators, in part to judge or rate hospitals, is mathematically invalid. The focus should shift from identifying 'outlier' hospitals to reducing the overall national mean Never Event rate through shared learning and an integrated system-wide approach.

Neurosurgical Wrong Surgical Site in Lower-Middle- or Low-Income Countries (LMICs): A Survey Study.

BACKGROUND: One of the most preventable errors of a surgeon's career is operating on the incorrect surgical site (ICSS). No study in any specialty has ever investigated the incidence of ICSS events in lower-income countries. This study focuses on identifying the occurrence of these events along with an analysis of potential causes leading to these unfortunate events. METHODS: The authors distributed a survey to neurosurgical colleagues from around the world. These surgeons were first asked to identify details about their practice and incidence and personal experience with ICSS in their own careers. At the end of the survey, they responded to questions about their knowledge of safety checklists. RESULTS: In this study there was a 63.4% response rate. When combined with those who participated through various social media platforms, there were 178 responses. The incidence rate for every 10,000 cases performed was found to be 22.8 in the cranial group, 88.6 in the cervical group, and 158.8 in the lumbar procedural group. This study identified that 40% of participants had never learned or experienced the ABCD time-out strategy and that 60% of surgeons did not use intraoperative navigation or imaging in their practices. The error has never been disclosed to the patient in 48% of the ICSS cases. CONCLUSIONS: Due to a lack of application of safety checklist protocol, there is an increased occurrence of ICSS events in lower-income countries. The results of this study demonstrate the necessity of investing time and resources dedicated to avoiding preventable errors.