Surgery Adverse Events Research Articles

Non-technical skills and teamwork in trauma: from the emergency department to the operating room.

Management of a trauma patient is a challenging process. Swift and accurate clinical assessment is required and time-sensitive decisions and life-saving procedures must be performed in an unstable patient. This requires a coordinated response by both the emergency room (ER) and operating room (OR) teams. However, a team of experts does not necessarily make an expert team. Root cause analysis of adverse events in surgery has shown that failures in coordination, planning, task management and particularly communication are the main causes for medical errors. While most research is focused on the ER trauma team, the trauma OR team also deserves attention. In fact, OR team dynamics may resemble more the ER team than the elective OR team. ER and OR trauma teams assemble on short notice, and their members, who are from different specialties and backgrounds, may not train regularly together or even know each other beforehand. And yet, they have to perform high-risk procedures and make high stake decisions, in a time-sensitive manner. The airline industry has long recognized the role of team training and non-technical skills (NTS) in reducing hazards. The implementation of the so called crew resource management or crisis resource management (CRM) has significantly made airline travel safer and the transposition to the medical context, with specific training in non-technical skills, has also brought great benefits. In fact, it is clear that adoption of non-technical skills (NTS) in healthcare has led to an increase in patient safety. In this narrative review we recapitulate some of the key non-technical skills and their relevance in trauma, with a focus on both the emergency department (ER) and the operating room (OR) teams, as well as on the transition of care from one to the other. Also, we explore the use of debriefing the team, as well as the roles of NTS training in both undergraduate and postgraduate settings. We review some of the existing trauma training courses and their roles in developing NTS. Finally, we briefly address the challenges posed by the development of trauma hybrid operating rooms.

Severity Grading Systems for Intraoperative Adverse Events. A Systematic Review of the Literature and Citation Analysis.

The accurate assessment and grading of adverse events (AE) is essential to ensure comparisons between surgical procedures and outcomes. The current lack of a standardized severity grading system may limit our understanding of the true morbidity attributed to AEs in surgery. The aim of this study is to review the prevalence in which intraoperative adverse event (iAE) severity grading systems are used in the literature, evaluate the strengths and limitations of these systems, and appraise their applicability in clinical studies. A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Web of Science, and Scopus were queried to yield all clinical studies reporting the proposal and/or the validation of iAE severity grading systems. Google Scholar, Web of Science, and Scopus were searched separately to identify the articles citing the systems to grade iAEs identified in the first search. Our search yielded 2957 studies, with 7 studies considered for the qualitative synthesis. Five studies considered only surgical/interventional iAEs, while two considered both surgical/interventional and anesthesiologic iAEs. Two included studies validated the iAE severity grading system prospectively. A total of 357 citations were retrieved, with an overall self/non-self-citation ratio of 0.17 (53/304). The majority of citing articles were clinical studies (44.1%). The average number of citations per year was 6.7 citations for each classification/severity system, with only 2.05 citations/year for clinical studies. Of the 158 clinical studies citing the severity grading systems, only 90 (56.9%) used them to grade the iAEs. The appraisal of applicability (mean%/median%) was below the 70% threshold in 3 domains: stakeholder involvement (46/47), clarity of presentation (65/67), and applicability (57/56). Seven severity grading systems for iAEs have been published in the last decade. Despite the importance of collecting and grading the iAEs, these systems are poorly adopted, with only a few studies per year using them. A uniform globally implemented severity grading system is needed to produce comparable data across studies and develop strategies to decrease iAEs further improving patient safety.

A Conceptual Framework for Prevention of Chronic Postsurgical Pain

Chronic postsurgical pain is one of the most common adverse events of surgery. The pain characteristics can occur as nociceptive pain and neuropathic pain or mixed, creating long-term suffering for patients. At present, there are no techniques for the prevention of this pain. However, anticipation of this condition must be done based on predictive concepts to control the risk factors, such as careful preoperative assessment, adequate perioperative pain management, adjusting surgical techniques that reduce tissue destruction, psychological support, improving physical function, and a multidisciplinary team working. Moreover, patient care needs to be considered individually in conjunction with formulating a patient care plan for each type of surgery. In particular, the International Association for the Study of Pain and the World Health Organization collaborated by establishing a definition of chronic postoperative pain and implemented it in the International Classification of Disease-11 for guidance in the study of prevalence and clinical symptoms. It will improve the strategy for the prevention and treatment of this condition. Keywords: Prevention; Chronic pain; Persistent; Postsurgical pain

Retroperitoneal teratomas in children: a single institution experience.

Retroperitoneal teratomas (RPTs) are rare in infants. We report our experience of treating pediatric patients with RPTs over many years at a single institution, with the aim of developing a safe and secure operative strategy for RPTs in infants. We reviewed the medical records of patients who underwent treatment for RPTs in our institution between April, 1984 and December, 2017, to analyze their background and clinical data. The diagnosis of RPT was confirmed histologically in all patients. The subjects of this retrospective analysis were 14 pediatric patients (female, n = 11; male, n = 4), ranging in age from 6days to 12years, 11 (73.3%) of whom were under 1year of age. Complete surgical resection was performed in all patients. The tumor ruptured during surgery in four (26.7%) patients and perioperative vessel injuries occurred in six (40.0%) patients, resulting in nephrectomy in one (6.7%). Three (20.0%) patients suffered unilateral renal dysfunction as a surgical complication. Only one patient received postoperative chemotherapy. All patients were free of disease at the time of writing. Perioperative complications are not uncommon during surgery for RPTs, despite their benign nature. Preoperative imaging evaluation is important and operative management may be challenging. Because of the favorable prognosis and the frequency of adverse events in surgery, partial resection or split excision is sometimes unavoidable. Meticulous follow-up for recurrence is required for such patients.

The Obesity Paradox in Elderly Patients Undergoing Emergency Surgery: A Nationwide Analysis

BackgroundObesity has long been considered a risk factor for postoperative adverse events in surgery. We sought to study the impact of body mass index (BMI) on the clinical outcomes of the high-risk emergency general surgery (EGS) elderly patients. MethodsAll EGS ≥65 years old patients in the 2007-2016 ACS-NSQIP database, identified using the variables ‘emergency’ and ‘surgspec,’ were included. Patients were classified into five groups: normal weight: BMI <25 kg/m2, overweight: BMI ≥25 kg/m2 and <30 kg/m2, Class I: BMI ≥30 kg/m2 and <35 kg/m2, Class II: BMI ≥35 kg/m2 and <40 kg/m2, and Class III: BMI ≥40 kg/m2. Patients with BMI<18.5 kg/m2 were excluded. Multivariable logistic regression models were built to assess the relationship between obesity and 30-day postoperative mortality, overall morbidity, and individual postoperative complications after adjusting for demographics (e.g., age, gender), comorbidities (e.g., diabetes mellitus, heart failure), laboratory tests (e.g., white blood cell count, albumin), and operative complexity (e.g., ASA classification). ResultsA total of 78,704 patients were included, of which 26,011 were overweight (33.1%), 13,897 (17.6%) had Class I obesity, 5904 (7.5%) had Class II obesity, and 4490 (5.7%) had Class III obesity. On multivariable analyses, compared to the nonobese, patients who are overweight or with Class I-III obesity paradoxically had a lower risk of mortality, bleeding requiring transfusion, pneumonia, stroke and myocardial infarction (MI). Additionally, the incidence of MI and stroke decreased in a stepwise fashion as BMI progressed from overweight to severely obese (MI: OR: 0.84 [0.73-0.95], OR: 0.73 [0.62-0.86], OR: 0.66 [0.52-0.83], OR: 0.51 [0.38-0.68]; stroke: OR: 0.80 [0.65-0.99], OR: 0.79 [0.62-1.02], OR: 0.71 [0.50-1.00], OR: 0.43 [0.28-0.68]). ConclusionIn our study of elderly EGS patients, overweight and obese patients had a lower risk of mortality, bleeding requiring transfusion, pneumonia, reintubation, stroke, and MI. Further studies are needed to confirm and investigate the obesity paradox in this patient population.

Semantically Ambiguous Language in the Teaching Operating Room

Teaching and training surgeons work hard in the OR to understand each other, yet miscommunication is an important cause of preventable adverse events in surgery. Our objective was to perform a formal semantic analysis of language in authentic teaching surgical cases, identify the prevalence and typology of ambiguous or potentially ambiguous language, and describe their potential for miscommunication. In this secondary analysis of qualitative data, we collaborated with a semanticist, categorizing linguistic phenomena often associated with miscommunication. We defined an ambiguous phenomenon as a string of language that could be reasonably interpreted in more than one way. We analyzed transcripts of 319 minutes of surgery, coding for 14 linguistic categories.Cohen's kappa was calculated.We determined the prevalence and rate of each linguistic category and chose illustrative examples. Six surgical attendings, four fellows, and six residents, ranging from PGY1 to PGY4, at the University of Pittsburgh Medical Center, a tertiary medical center in Pittsburgh, Pennsylvania. We found 3912 examples of potentially ambiguous language, 12.3 per minute. Percentage agreement between two expert raters was 76.3%. The most common phenomena were deixis (3.1 per minute), directional (2.6), anaphora (1.3), implicit instruction (1.3), and degree modifiers (0.7). Restatements/reframing occurred 1.4 times per minute. We identified 131 near misses associated with potentially ambiguous language. Cohen's kappa was 0.70 among expert semanticists. Potentially ambiguous language is common and has the potential to jeopardize safe teaching surgery. We postulate that the high amount of potentially ambiguous language use in the operating room places a burden on the training surgeon to comprehend surgical instruction.

Barriers to reporting near misses and adverse events among professionals performing laparoscopic surgeries: a mixed methodology approach.

The literature has investigated barriers to reporting adverse events in surgery, but with less emphasis on near misses. No attempt was made to categorise near misses by type and reportability. This paper attempts to fill these two gaps in the literature. A mixed methodology approach was adopted. A sample of 16 laparoscopic surgeries were observed followed by a questionnaire distributed among professionals dealing with laparoscopies. Non-parametric tests and mediation-moderation analysis were used to compare responses and identify causal factors. A total of 469 near misses were observed, and classified into two categories: reportable events and common events. Among 23 observed reportable events, only 9 events were reported. Out of 300 distributed questionnaires, we received 178 valid responses (response rate 59%). The professionals strongly disagreed that reporting near misses (Mean 4.09, STD 0.95) and adverse events (4.17, 1.02) makes little contribution to the quality of surgery. However, the results show that professionals were more willing to disclose adverse events than near misses, Heavy workload, privacy, lack of support, and fear from disciplinary actions negatively affected professionals' willingness to report near misses. Error reporting should aim to promote safety, knowledge sharing and education. It is important to differentiate near misses that should be reported from voluntary reported events. Hospital's management might award professionals who frequently report errors and provide solutions, Quality rather than quantity of reports should be emphasised with flexibility in the way near misses are reported. The outcome of this study has benefits of understanding the attitudes of surgical professionals towards error reporting. It provides healthcare management with tool for enhancing safety and providing suitable training for their professionals.

Procedimentos cirúrgicos assistidos pelo robô Da Vinci: benefícios, riscos e responsabilidade civil

Objetivo: verificar benefícios, riscos e eventos adversos na utilização da cirurgia assistida pelo robô Da Vinci, a fim de estabelecer a forma de atribuição de responsabilidade entre os diversos agentes envolvidos, quais sejam, ­ médico, hospital, equipe de enfermagem e fabricante. Metodologia: o presente estudo centra-se na coleta e interpretação de material doutrinário e jurisprudencial relacionado à temática, sendo, inicialmente, realizado por meio da investigação dos benefícios, riscos e litígios que discutem eventos adversos na cirurgia assistida pelo robô Da Vinci, à luz do ordenamento jurídico norte-americano. Num segundo momento, é traçado um estudo comparatístico dessas demandas, sob a ótica do sistema jurídico brasileiro. Resultados e discussão: a grande complexidade na análise da responsabilidade civil na cirurgia robótica dá-se, sobretudo, na determinação da causa eficiente do dano – e a quem se atribuir o dever de indenizar. Nos Estados Unidos, essas demandas indenizatórias são conhecidas como finger-pointing cases, pois há sempre o dilema de quem deve responder quando há um dano ao paciente submetido à cirurgia robótica: o médico (e/ou o hospital) ou o fabricante do equipamento. Conclusão: para determinar a responsabilidade civil por eventos adversos na cirurgia robótica, torna-se imprescindível determinar a gênese do dano, isto é, se o dano é decorrente de serviço essencialmente médico, paramédico ou extramédico. Além disso, na eventualidade de defeito do próprio robô Da Vinci, responderá o fabricante, independentemente da existência de culpa, pela reparação dos danos causados ao paciente.

Impact of left ventricular ejection fraction on the outcomes of open repair of descending thoracic and thoracoabdominal aneurysms

ObjectiveTo discern the impact of depressed left ventricular ejection fraction (LVEF) on the outcomes of open descending thoracic aneurysm (DTA) and thoracoabdominal aneurysms (TAAA) repair. MethodsRestricted cubic spline analysis was used to identify a threshold of LVEF, which corresponded to an increase in operative mortality and major adverse events (MAE: operative death, myocardial infarction, stroke, spinal cord injury, need for tracheostomy or dialysis). Logistic and Cox regression were performed to identify independent predictors of MAE, operative mortality, and survival. ResultsDTA/TAAA repair was performed in 833 patients between 1997 and 2018. Restricted cubic spline analysis showed that patients with LVEF <40% (n = 66) had an increased risk of MAE (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.22-3.87; P < .01) and operative mortality (OR, 2.72; 95% CI, 1.21-6.12; P = .02) compared with the group with LVEF ≥40% (n = 767). The group with LVEF <40% had a worse preoperative profile (eg, coronary revascularization, 48.5% vs 17.3% [P < .01]; valvular disease, 82.8% vs 49.39% [P < .01]; renal insufficiency, 45.5% vs 26.1% [P < .01]; respiratory insufficiency, 36.4% vs 21.2% [P = .01]) and worse long-term survival (35.5% vs 44.7% at 10 years; P = .01). Nonetheless, on multivariate regression, depressed LVEF was not an independent predictor of operative mortality, MAE, or survival. ConclusionsLVEF is not an independent predictor of adverse events in surgery for DTA.

The role of additional hysterectomy after concurrent chemoradiation for patients with locally advanced cervical cancer

The standard treatment for cervical cancer is chemoradiation although some patients showed treatment resistance. The purpose of this study was to investigate the clinical efficacy of surgery after chemoradiation for cervical cancer. Patients with FIGO stage IB2 to IIB cervical cancer were included in the study between 2005 and 2015. A total of 50 patients who underwent surgery after neoadjuvant chemoradiation and 76 patients who received only chemoradiation were compared. Baseline differences between the two groups were adjusted with inverse probability of treatment weighting method using propensity scores composed of the following independent variables: age, stage, tumor size, lymph node metastasis, and histological subtypes. Median follow-up was 64.8 (range 4.8-143.9) months. After adjustment with inverse probability of treatment weighting, Kaplan-Meier curves showing adjusted progression-free survival and overall survival were significantly longer in the neoadjuvant chemoradiation compared with the chemoradiation-only group (p = 0.027 and p = 0.017, respectively). Moreover, in patients with squamous cell carcinoma, recurrence in previously irradiated field and recurrence both in and out of previously irradiated field were significantly decreased in the neoadjuvant chemoradiation compared with the chemoradiation-only group (3.1% and 18.4%, respectively; OR 0.142, p = 0.001]. Adverse events of surgery after chemoradiation were acceptable, although temporary hydronephrosis was frequently observed (23.1%). Surgery after chemoradiation reduced pelvic recurrence, and as a result, patients who underwent neoadjuvant chemoradiation showed more favorable survival outcomes compared with those who only underwent chemoradiation.

Disclosure of errors and adverse events in surgery; a cross-sectional survey of attitude and experience of surgeons in Saudi Arabia

Background: Adverse events (AE’s) and medical errors are frequent medical practice and they are responsible for a considerable rate of morbidity and mortality events. AEs and medical errors are more prone to occur in surgery specialty. Attention to patient safety is of growing concern and disclosure of medical errors to patients is very important and highly recommended. The present study aimed to assess the attitude and experience of surgeons on AEs and errors in surgery. Methodology: A cross-sectional study was conducted among the surgeons practicing at different hospitals in Saudi Arabia. The study took part between the period of June to August 2019 using a self-administrated questionnaire. Results: This study included a total of 200 surgeons, among them, 15% agreed and 5% strongly agreed for disclosure of AEs. Furthermore, 40% agreed to disclose near misses, 30% agreed to disclose minor errors, and 5% agreed to disclose serious errors. Also, 65% of the subjects were found to involve in minor error, 15% in serious error and 5% in AEs. Conclusion: The study found that there was a negative attitude of surgeon toward disclosure of AEs and errors to patients and there was a moderate experience of AEs and errors.

Tell Me Straight: Teaching Residents to Disclose Adverse Events in Surgery

The purpose of this effort was to create an educational experience that provided learners a realistic disclosure experience and improved resident confidence discussing an adverse outcome with a patient and family. Residents practiced disclosing a surgical complication to a patient/family with simulated patients (SPs). We paired professional SPs with former patient SPs to present a realistic case. Junior residents were given extra training time before their disclosure of a laparoscopic cholecystectomy conversion to an open procedure; senior residents disclosed a bile duct injury. Residents rated pre and post-module confidence levels, and skills performance using the Disclosure of a Complication Checklist. 900-bed tertiary care hospital with surgical residency program and simulation center. General surgery residents (PGY 1-5). Eighteen residents participated in the disclosure module. Analysis of the medians and interquartile ranges of pre and post-module confidence scores showed significant improvement for each individual item and mean score of learners. Residents assessed their completion rates of individual Checklist tasks positively. For example, 94% self-endorsed completion of "explanation of facts," 89% self-endorsed "took responsibility," and 78% self-endorsed "apologized sincerely." Self-rated competence scores from the Checklist were low: 7% indicated they would be "extremely comfortable" entrusting their loved one's care to themselves, 11% rated their ability to explain the facts as "outstanding," and 12% felt they were "outstanding" in their "ability to disclose a complication in a professional manner." Residents received important skills practice in our disclosure training; disclosure confidence increased after participation. Residents scored high on completion of disclosure tasks and low on comfort and proficiency of those tasks. The Checklist provided a useful set of tasks to review and complete in the exercise. Separating residents by PGY level enabled senior residents to experience a more complex scenario and junior residents extra time to practice.

Communication through simulation: Developing a curriculum to teach interpersonal skills

BackgroundNontechnical issues are linked to up to 60% of adverse events in surgery and have become one of the core competencies of surgical education. Simulation-based training allows development of these skills. We hypothesized that we could both assess and improve the communication skills of interdisciplinary teams through a simulated crisis situation. MethodsWe designed a simulated crisis involving the intraoperative development of a tension pneumothorax. Audiovisual analysis was used to evaluate team interaction, and a combination of proctored assessment and self-assessment was used to evaluate individual learners. Time to communication and event intervention was measured. Data were analyzed using paired t-tests and 1-way analysis of variance in SPSS. ResultsTime from development of hypotension to communication of deterioration was 57 ± 60 seconds; time to intervention was 93 ± 30 seconds. Nontechnical skills in surgery II scores were greatest for surgery senior residents and least for surgery junior residents. Insight was least in surgery junior residents. Correctability was not different between groups but tended to be greater in surgery junior residents. ConclusionsPoor communication delayed timing of intervention, indicating a need for enhanced communication in the operating room. Junior surgery residents scored lowest both on nontechnical skills and insight and should be taught nontechnical skills through simulation. Our curriculum is a suitable and reproducible model to educate surgery residents in communication skills.

Effects of a Brief Team Training Program on Surgical Teams' Nontechnical Skills: An Interrupted Time-Series Study.

Up to 60% of adverse events in surgery are the result of poor communication and teamwork. Nontechnical skills in surgery (NOTSS) are critical to the success of surgery and patient safety. The study aim was to evaluate the effect of a brief team training intervention on teams' observed NOTSS. Pretest-posttest interrupted time-series design with statistical process control analysis was used to detect longitudinal changes in teams' NOTSS. We evaluated NOTSS using the revised NOTECHS weekly for 20 to 25 weeks before and after implementation of a team training program. We observed 179 surgical procedures with cardiac, vascular, upper gastrointestinal, and hepatobiliary teams. Mean posttest NOTECHS scores increased across teams, showing special cause variation. There were also significant before and after improvements in NOTECHS scores in respect to professional role and in the use of the Surgical Safety Checklist. Our results suggest associated improvements in teams' NOTSS after implementation of the team training program.

PD46-07 SIMULATED WARD ROUNDS- A UNIQUE APPROACH TO TEACH NON-TECHNICAL SURGICAL SKILLS FOR NEWLY APPOINTED RESIDENTS IN UROLOGY

You have accessJournal of UrologySurgical Technology & Simulation: Training & Skills Assessment III1 Apr 2017PD46-07 SIMULATED WARD ROUNDS- A UNIQUE APPROACH TO TEACH NON-TECHNICAL SURGICAL SKILLS FOR NEWLY APPOINTED RESIDENTS IN UROLOGY Sanjay Rajpal, Uwais Mufti, Andy Myatt, Craig Mcllhenny, Chandra Shekar Biyani, and Sunjay Jain Sanjay RajpalSanjay Rajpal More articles by this author , Uwais MuftiUwais Mufti More articles by this author , Andy MyattAndy Myatt More articles by this author , Craig McllhennyCraig Mcllhenny More articles by this author , Chandra Shekar BiyaniChandra Shekar Biyani More articles by this author , and Sunjay JainSunjay Jain More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2379AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Residents encounter a step change in responsibility during their entry into speciality training and are often expected to run a ward round but are seldom given a formal training for its effective conduct. Along with technical skills, it is increasingly recognised that non-technical skills such as communication, team working and leadership play a vital role in reducing adverse events in surgery. Simulation based learning can be used to complement training. METHODS A ward round scenario was designed as one of the modules during a urology simulation boot camp for newly appointed trainees in urology. This module comprised simulated patients with typically encountered urological problems along with a nurse and intern. To test the non-technical skills, various interruptions and distractions were introduced. We assessed this module using structured feedback forms; self-reported confidence scores (5 point Likert scale) and also uniquely performed a cognitive load assessment using the NASA- Task load index (NASA TLX) multi-dimensional assessment tool. RESULTS 32 delegates attended the boot camp of which 19 were males. At the conclusion of this module, 83% delegates felt 'more confident' in running an acute urology ward round. 90% delegates felt challenged in decision making skills during the simulation and believed that they would change their behaviour in ward settings. A vast majority felt that the scenario helped them think critically, develop better insight into teamwork, improved communication skills and learn the importance of handover. 96% delegates enjoyed the exercise and would recommend to other trainees at their level. The cognitive load assessment using the NASA TLX (table 1) showed that among the six domains, performance and mental demand were the most challenging aspects in this module with mean scores of 12.1 and 11.9 respectively. Physical demand scored the least with mean score of 6.3. CONCLUSIONS We have demonstrated that simulation can improve the confidence of newly appointed residents in leading the ward rounds which in turn could result in improved patient care and better team working. The NASA TLX scale helps to identify the residents cognitive workload in different working environments and can facilitate learning technical and non-technical skills. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e892-e893 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Sanjay Rajpal More articles by this author Uwais Mufti More articles by this author Andy Myatt More articles by this author Craig Mcllhenny More articles by this author Chandra Shekar Biyani More articles by this author Sunjay Jain More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Infecciones en cirugía bariátrica

Surgical site infections are frequent adverse events in surgery, its presence determines increased morbidity and mortality plus hospital stay and economic costs for those affected.Obesity is a risk factor for this disease by multifactorial aspects. Considering the Western epidemic overweight and obesity, as well as the massification of bariatric surgery, it is important to keep updated concepts.Obesity determines a state of basal systemic inflammatory response, which can be decompensated by a second hit, this decompensation can determine a higher rate of infections associated to surgery.There is evidence that fails to demonstrate statistical significance in relation to the presence of diabetes or H. pylori infection as a risk factor. As a complement, some paradigms as the highest rate of lung infections or the need for antibiotic prophylaxis use in bariatric surgery remains.

Applied anatomical study of the modified anconeus flap approach.

Conventional surgical therapy for an intercondylar humerus fracture might result in multiple potential complications. Our study was conducted to evaluate the modified anconeus flap approach by adequately exposing the distal humeral articular surface, avoiding osteotomy of the olecranon and transection of the main part of the triceps brachial tendon from the olecranon. Preparations of 20 upper limb specimens from adult cadavers were used in this study. We investigated the anatomical features of the distal tendon of the triceps brachii. Then, we designed a modified anconeus flap approach in cadaver specimens combined with the medial paratricipital approach, and we compared the extent of exposure of the distal humeral articular surface between the triceps-reflecting anconeus pedicle approach and this modified approach. The downward neurovascular bundles supplying the anconeus were located far from the intramuscular tendon of the triceps brachii. In addition, the medial head of the triceps was continuous with the anconeus near the lateral epicondyle of the humerus. These anatomical properties could assist in reducing adverse events in surgery. The percentage of the exposed humerus distal articular surface was 42.7% by applying the modified anconeus flap approach combined with the medial paratricipital approach. The modified anconeus flap approach can overcome the shortcomings of osteotomy or triceps transverse and fulfill reduction and internal fixation of most distal humerus intercondylar fractures. The present study has demonstrated a new approach for adequately exposing the distal humeral articular surface during surgery for an intercondylar humerus fracture. With this modified approach, osteotomy of the olecranon and the separation or transection of the main part of the triceps brachial tendon from the olecranon are not necessarily required. Therefore, we suggest that this novel approach could be applied as the primary surgical approach in intercondylar humerus fracture surgeries if the surgeons are familiar with the regional features of distal tendon of the triceps brachii and anconeus.

SurgiCal Obesity Treatment Study (SCOTS): protocol for a national prospective cohort study of patients undergoing bariatric surgery in Scotland

IntroductionThe efficacy of bariatric surgery for large-scale, long-term weight loss is well established. However, many questions remain over the continual benefits and cost-effectiveness of that weight loss for overall health,...

How prevalent are hazardous attitudes among orthopaedic surgeons?

So-called "hazardous attitudes" (macho, impulsive, antiauthority, resignation, invulnerable, and confident) were identified by the Federal Aviation Administration and the Canadian Air Transport Administration as contributing to road traffic incidents among college-aged drivers and felt to be useful for the prevention of aviation accidents. The concept of hazardous attitudes may also be useful in understanding adverse events in surgery, but it has not been widely studied. We surveyed a cohort of orthopaedic surgeons to determine the following: (1) What is the prevalence of hazardous attitudes in a large cohort of orthopaedic surgeons? (2) Do practice setting and/or demographics influence variation in hazardous attitudes in our cohort of surgeons? (3) Do surgeons feel they work in a climate that promotes patient safety? We asked the members of the Science of Variation Group-fully trained, practicing orthopaedic and trauma surgeons from around the world-to complete a questionnaire validated in college-aged drivers measuring six attitudes associated with a greater likelihood of collision and used by pilots to assess and teach aviation safety. We accepted this validation as applicable to surgeons and modified the questionnaire accordingly. We also asked them to complete the Modified Safety Climate Questionnaire, a questionnaire assessing the absence of a safety climate that is based on the patient safety cultures in healthcare organizations instrument. Three hundred sixty-four orthopaedic surgeons participated, representing a 47% response rate of those with correct email addresses who were invited. Thirty-eight percent (137 of 364 surgeons) had at least one score that would have been considered dangerously high in pilots (> 20), including 102 with dangerous levels of macho (28%) and 41 with dangerous levels of self-confidence (11%). After accounting for possible confounding variables, the variables most closely associated with a macho attitude deemed hazardous in pilots were supervision of surgical trainees in the operating room (p = 0.003); location of practice in Canada (p = 0.059), Europe (p = 0.021), and the United States (p = 0.005); and being an orthopaedic trauma surgeon (p = 0.046) (when compared with general orthopaedic surgeons), but accounted for only 5.3% of the variance (p < 0.001). On average, 19% of surgeon responses to the Modified Safety Climate Questionnaire implied absence of a safety climate. Hazardous attitudes are common among orthopaedic surgeons and relate in small part to demographics and practice setting. Future studies should further validate the measure of hazardous attitudes among surgeons and determine if they are associated with preventable adverse events. We agree with aviation safety experts that awareness of amelioration of such attitudes might improve safety in all complex, high-risk endeavors, including surgery-a line of thinking that merits additional research.

Using a hybrid electronic medical record system for the surveillance of adverse surgical events and human error in a developing world surgical service.

The quantification and analysis of adverse events is essential to benchmark surgical outcomes and establish a foundation for quality improvement interventions. We developed a hybrid electronic medical record (HEMR) system for the accurate collection and integration of data into a structured morbidity and mortality (M&M) meeting. The HEMR system was implemented on January 1, 2013. It included a mechanism to capture and classify adverse events using the ICD-10 coding system. This was achieved by both prospective reporting by clients and by retrospective sentinel-event-trawling performed by administrators. From January 1, 2013 to March 20, 2014, 6,217 patients were admitted within the tertiary surgical service of Greys Hospital. A total of 1,314 (21.1 %) adverse events and 315 (5.1 %) deaths were recorded. The adverse events were divided into 875 "pathology-related" morbidities and 439 "error-related" morbidities. Pathology-related morbidities included 725 systemic complications and 150 operative complications. Error-related morbidities included 257 cognitive errors, 158 (2.5 %) iatrogenic injuries, and 24 (1.3 %) missed injuries. Error accounted for 439 (33 %) of the total number of adverse events. A total of 938 (71.4 %) adverse events were captured prospectively, whereas the remaining 376 (28.6 %) were captured retrospectively. The ICD-10 coding system was found to have some limitations in its classification of adverse events. The HEMR system has provided the necessary platform within our service to benchmark the incidence of adverse events. The use of the international ICD-10 coding system has identified some limitations in its ability to classify and categorise adverse events in surgery.