Abstract
Background: Since bleedings in surgery are infrequent and inexperienced, we always try to proceed with surgery assuming a crisis situation, adhere to routine procedures and its standardization. We focus on the bleeding accidents and reveal how to implement a resilient healthcare theory. By clarifying the Safety-I and Safety-II, we developed a system to support surgical safety based on the surgeon’s individual, team, and organization. Material and Methods: We searched 25 cases of bleeding incidents in thoracic surgery, which were obtained from the database of the Project to Collect Medical Near-Miss/Adverse Event Information of the Japan Council of Quality Health Care in April 2018. Retrospectively, we analyzed 13 hemorrhage cases in our department between July 2002 and March 2020. We studied their surgical factors such as procedures, sites and causes of bleeding, response, treatment, and outcomes. Results: The causes of bleeding included damage of the adhesion detachment, insertions of automatic sutures and forceps, detachment of ultrasonic scalpel, vascular taping, removal of resected lung, lymph node dissection, exfoliation of the infiltrated adventitia of vessels, pull-out of vessel, gauze attachment with staple cut-line of vessel, thoracoscopic collision, infectious vascular rupture, detachment of vascular ligature, and suction tube hit. We summarized the variation in the usual controllable and unexpected uncontrollable bleeding and learned how to respond and treat them. We built up the balanced combination of Safety-I and Safety-II in the daily routine work in normal surgery, the patient’s individual factors, the massive bleeding, and its life-threatening crisis. Conclusions: We can learn how to prevent and respond to bleeding accidents by developing a system to support surgical safety (Safety-I and Safety-II). We can flexibly respond to unexpected bleeding disturbances under constraints by adjusting the surgeon’s individuals, team, and organization.
Highlights
Until now, the basics of industrial safety have been “safety means that there are no accidents” and “learning from failures”
By clarifying the Safety-I and Safety-II, we developed a system to support surgical safety based on the surgeon’s individual, team, and organization
Both the concepts of Safety-I and Safety-II are important for surgical safety and should be balanced in the combination of Safety-I + Safety-II
Summary
The basics of industrial safety have been “safety means that there are no accidents” and “learning from failures”. In Japan, similar efforts in medical care began in 1999, and today, various patient safety measures are being implemented at medical institutions in Japan and overseas, but they face common challenges This includes the following 1), 2), and 3). It is centered on learning from what’s going on and improving the resilience ability. Resilience means the ability of individuals, teams, and organizations to make various adjustments (adjustments and ingenuity) according to the situation and flexibly respond In this new approach to safety (Safety-II), “safety is defined as the ability to perform the required tasks and functions even in unexpected situations.”. We analyzed 13 hemorrhage cases in our department between July 2002 and March 2020 We studied their surgical factors such as procedures, sites and causes of bleeding, response, treatment, and outcomes. Conclusions: We can learn how to prevent and respond to bleeding acci-
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