Surgical Errors Research Articles

Three-dimensional printing accuracy analysis for medical applications across a wide variety of printers.

Three-dimensional (3D) printing has had a significant impact on patient care. However, there is a lack of standardization in quality assurance (QA) to ensure printing accuracy and precision given multiple printing technologies, variability across vendors, and inter-printer reliability issues. We investigated printing accuracy on a diverse selection of 3D printers commonly used in the medical field. A specially designed 3D printing QA phantom was periodically printed on 16 printers used in our practice, covering five distinct printing technologies and eight different vendors. Longitudinal data were acquired over six months by printing the QA phantom monthly on each printer. Qualitative assessment and quantitative measurements were obtained for each printed phantom. Accuracy and precision were assessed by comparing quantitative measurements with reference values of the phantom. Data were then compared among printer models, vendors, and printing technologies; longitudinal trends were also analyzed. Differences in 3D printing accuracy across printers were observed. Material jetting and vat photopolymerization printers were found to be the most accurate. Printers using the same 3D printing technology but from different vendors also showed differences in accuracy, most notably between vat photopolymerization printers from two different vendors. Furthermore, differences in accuracy were found between printers from the same vendor using the same printing technology, but different models/generations. These results show how factors such as printing technology, vendor, and printer model can impact 3D printing accuracy, which should be appropriately considered in practice to avoid potential medical or surgical errors.

PD30-03 IMPORTANCE OF COGNITIVE LOAD FOR AUTOMATED ERROR DETECTION IN ROBOT-ASSISTED SURGERY EDUCATION

You have accessJournal of UrologyCME1 Apr 2023PD30-03 IMPORTANCE OF COGNITIVE LOAD FOR AUTOMATED ERROR DETECTION IN ROBOT-ASSISTED SURGERY EDUCATION Rafal Kocielnik, Jasper A. Laca, Elyssa Y. Wong, Timothy N. Chu, Sidney I. Roberts, Sandra Marshall, Anima Anandkumar, and Andrew J. Hung Rafal KocielnikRafal Kocielnik More articles by this author , Jasper A. LacaJasper A. Laca More articles by this author , Elyssa Y. WongElyssa Y. Wong More articles by this author , Timothy N. ChuTimothy N. Chu More articles by this author , Sidney I. RobertsSidney I. Roberts More articles by this author , Sandra MarshallSandra Marshall More articles by this author , Anima AnandkumarAnima Anandkumar More articles by this author , and Andrew J. HungAndrew J. Hung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003316.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cognitive Load (CL) can affect surgeon performance and the ability of training surgeons to receive feedback. We investigate the value of CL for detecting surgical errors in robot-assisted surgery (RAS) with a machine learning (ML)-based model. METHODS: We use 2 datasets (DS1, DS2) where 24 and 44 surgeons, respectively, performed a simulated dry-lab tissue dissection task on a live daVinci Xi surgical robot. The data contains video and per-second Index of Cognitive Activity (ICA), derived from pupillary change tracked via Tobii Eyetrackers. DS1 includes surgeons with low, medium, and high experience (by hours of RAS) as well as annotated tissue Tear (n=70) and Puncture (n=62) errors. DS2 contains data from low experience surgeons only and annotations for Tears (n=445) and Punctures (n=527). We extract 5 sec of video and varying history of ICA (from 5 to 60 sec) before and around human-labeled errors (positive label). We randomly sample the remaining data (negative label). We train variations of ML architecture consisting of video processing (pretrained Resnet18) and/or ICA processing (LSTM). We train the model on 3 different 80/20 train-test between-participant random splits. RESULTS: When including surgeons of mixed experience levels (DS1), ICA alone (AUC=64.28) is competitive with video alone (AUC=62.59) in detecting surgical errors (Figure 1A). However, the use of ICA in combination with video improves AUC in both datasets with gains of 5.55 (DS1) and 3.24 (DS2). History of ICA up to 20-30 seconds seems beneficial for error detection, after which point there is no further gain (Figure 1B). This is likely attributed to gradual build-up in CL leading to an error, and low-frequency of ICA measurements (1/sec), which may hinder extracting useful information from short time windows. The challenge of extracting meaningful information seems supported by Figure 1C, where providing processed ICA is beneficial (AUC=62.95) on top of raw ICA measurements (AUC=58.88). CONCLUSIONS: A surgeon’s CL in the context of surgical errors in RAS education is important. We show how CL is particularly valuable when a dataset includes mixed-experience surgeons. We also show the importance of ICA history length and pre-processing. Further work will explore better methods of extracting valuable features from CL data and its importance in surgery. Source of Funding: This material is based upon work supported by the National Science Foundation under Grant # 2030859 to the Computing Research Association for the CIFellows Project. Additionally, research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R01CA273031. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e831 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rafal Kocielnik More articles by this author Jasper A. Laca More articles by this author Elyssa Y. Wong More articles by this author Timothy N. Chu More articles by this author Sidney I. Roberts More articles by this author Sandra Marshall More articles by this author Anima Anandkumar More articles by this author Andrew J. Hung More articles by this author Expand All Advertisement PDF downloadLoading ...

Awareness of the culture of patient safety among medical staff in neurosurgery departments from Moldova

To improve outcomes for patients and prevent avoidable surgical errors, neurosurgeons must change the culture of patient safety. The purpose of the study was to explore the perception of Patient Safety Culture (PSC) and the factors influencing it among the staff in the neurosurgical departments from Republic of Moldova. Material and methods. A cross sectional study was conducted in neurosurgical departments using the Hospital Survey on Patient Safety Culture (HSOPSC). Descriptive statistics were carried out, comprised the Cronbach “α” coefficient, frequency of positive answers (PPRs), level of minimum and maximum of 95% confidential interval, F. Galton correlation coefficient, Kendall rank coefficient, Harrington scale. Results. Medical staff from neurosurgical departments from five hospitals voluntarily participated in the study n=345. Most of the respondents rated the patient’s safety grade as “excellent” and “very good”. The value of the frequency of positive responses to the dimensions of the survey varies between 37.3% (CI 95% [34.8-39.9]) (staffing) and 85.0% (CI.95% [83.1-86.9]) (teamwork within units). The dimensions with the highest score of the PPRs stand out: „teamwork within units”, „organizational learning- continuous improvement” and „supervisor/manager expectations and actions promoting patient safety”. Analyzing the effect of the influence of patient safety culture factors on the degree of patient safety appreciated by the staff, we notice that the dimensions with the greatest influence are “Feedback and Communication About Error”, “Teamwork Across Units”, “Management Support for Patient Safety”, “Handoffs and transitions”, “Communication openness”. We found significant correlations among patient safety culture composites with the degree of patient safety with differences in the strength of the correlation. Conclusions. The results reflected the positive attitude of the staff towards most composites of the patient safety culture. The study made it possible to highlight the strong and vulnerable points of the patient safety culture and the factors influencing the patient safety degree in neurosurgical departments from Moldova.

Profile and Outcome of Obstetric Fistula Surgeries in a Fistula Care Centre in South-East Nigeria

Prolonged obstructed labour is the main cause of obstetric vesico-vaginal fistula, however there is growing perception that a proportion of cases may be arising from surgical complications and errors. This study intends to evaluate this observation. A retrospective study of 378 eligible cases of obstetric VVF repaired over a five-year period. Requisite information was retrieved from hospital case records. Dataentry and analysis was done using SPSS version 20. Means and SD, Chi square test and the level of significance set at p<0.05 were calculated. The mean age was 33.9±10.1 years, mostly multipara, majority following caesarean sections in 62.3% followed by prolonged obstructed labour in 28.6% of patients. The most common type of VVF was Intra-cervical fistula in 55.8% of patients. At the time of hospital discharge following repair, 76.5% were closed and dry, 18.5% had post-repair incontinence and 5.0% had a failed repair within the studied period. Half of our patients (50.3%) were referred from private hospitals, 40.3% had no referral letter and the remaining were referred from government hospitals. The outcomes of surgeries were not influenced by the type of VVF repaired. Chi square test was 0.38 at 95% CI (p>0.05). There is a worrisome proportion of obstetric VVF from caesarean sections. Our success rates in obstetric VVF repair appears satisfactory; more effort be made in strengthening the referral system and impacting correct surgical skills especially in areas of caesarean section.

Digital template-guided genioplasty for patients with jaw deformity resulting from temporomandibular joint ankylosis: A comparison between single- and double-layer genioplasty

The aim of this study was to compare single- and double-layer digital template-assisted genioplasty for the correction of jaw deformity resulting from temporomandibular joint ankylosis (TMJA). Thirteen patients with jaw deformity resulting from TMJA who underwent lateral arthroplasty, costochondral graft, or total joint replacement combined with single- or double-layer digital template-assisted genioplasty were included. Computed tomography data were obtained for the preoperative design. Digital templates were designed and manufactured using three-dimensional printing to assist with the chin osteotomy and repositioning in single- or double-layer genioplasty. Of the 13 patients included, seven underwent single-layer genioplasty and six underwent double-layer genioplasty. The digital templates precisely reflected the osteotomy planes and repositioning of the chin segments intraoperatively. The radiographic evaluation showed that the patients who underwent double-layer genioplasty exhibited more chin advancement (11.95 ± 0.92 mm vs 7.50 ± 0.89 mm; P < 0.001) with a slightly larger mean surface error (1.19 ± 0.14 mm vs 0.75 ± 0.15 mm; P < 0.001) than those who underwent single-layer genioplasty. This indicates that double-layer genioplasty better promoted chin advancement and improved the facial shape, but was accompanied by more surgical error compared with the preoperative design. Furthermore, hardly any nerve damage was observed. Digital templates are useful for assisting in surgical procedures.

Beyond the Surgical Safety Checklist: Using Intraoperative Handoff to Facilitate Team Situation Awareness in the OR.

The surgical safety checklist (SSC) has been credited with improving team situation awareness (SA) in the operating room. Although the SSC may support team SA at the outset of the operative case, intraoperative handoff provides an opportunity for either SA breakdown or, more preferably, SA reinforcement. High-functioning surgical teams demonstrate a high level of continued SA, whereas teams deficient in SA are more likely to be affected by surgical errors and adverse events. To date, no interprofessional intraoperative tools exist to support team SA beyond the SSC. This study was divided into 2 phases. The first used qualitative methods to (1) characterize intraoperative handoff processes across surgery, nursing, anesthesia, and perfusion, and (2) identify cultural factors that shaped handoff practices. Data for phase one were collected over 38 observation days and 41 brief interviews. Phase 2, informed by phase 1, used a modified Delphi process to create a tool for use during intraoperative handoff. Data were analyzed iteratively. Handoff practices were not standardized and rarely involved the entire team. In addition we uncovered cultural factors-specifically assumptions held by participants-that hindered team communication during handoff. Assumptions included: (1) team members are interchangeable, (2) trained individuals are able to determine when it is appropriate to handoff without consulting the OR team. Despite claims of improved teamwork resulting from the SSC, many participants held a fragmented view of the OR team, resulting in communication challenges during handoff. Findings from both phases of our study informed the development of multidisciplinary intraoperative handoff tools to facilitate shared team situation awareness and a shared mental model. Intraoperative handoff occurs frequently, and offers the opportunity for either renewed or fractured team SA beyond the SSC.

First worldwide report on Hugo RAS™ surgical platform in right and left colectomy.

The diffusion of robotic surgery is rapidly and constantly growing in different surgical specialties. Recently, novel robotic platforms have entered into the market. To date, however, most of the reports on their clinical use have specifically focused on gynecological and urological surgery. In this study, we present the first three robotic-assisted colectomies performed with the new Hugo RAS system (Medtronic, Minneapolis, MN, USA). The surgical team had previous robotic experience and completed simulation training and an official 2-day cadaver laboratory session. Operating room setting and trocar layout were planned and two full cadaver procedures were carried out (right and left colectomy). Onsite dry-run sessions were performed before tackling clinical cases. Three patients underwent robotic-assisted colectomies: one left colectomy, two right colectomies with complete mesocolic excision (CME) and high vascular ligation (HVL) at our Institution. Preoperative diagnosis was colonic adenocarcinoma in all cases. A description of the operative room setup, robotic arm configuration and docking angles is provided. Mean docking time and console time were 8 and 259min, respectively. All the surgical steps were completed without critical surgical errors or high-priority alarms. Neither intraoperative complications nor conversions to open surgery were recorded. Postoperative courses were uneventful with a mean length of stay of 5days. Further clinical data and experience are required for procedural standardization and potential integration of the system into robotic general surgery and colorectal programs.

Evaluation of a Microsurgery Training Curriculum.

Microsurgery is one of the most challenging areas of surgery with a steep learning curve. To address this educational need, microsurgery curricula have been developed and validated, with the majority focus on technical skills only. The aim of this study was to report on the evaluation of a well-established curriculum using the Kirkpatrick model. A training curriculum was delivered over 5 days between 2017 and 2020 focusing on (1) microscopic field manipulation, (2) knot tying, nondominant hand usage, (3) 3-D models/anastomosis, and (4) tissue experience. The Kirkpatrick model was applied to evaluate the curriculum at four levels: (1) participants' feedback (2) skills development using a validated, objective assessment tool (Global Assessment Score form) and CUSUM charts were constructed to model proficiency gain (3) and (4) assessing skill retention/long-term impact. In total, 155 participants undertook the curriculum, totaling 5,425 hours of training. More than 75% of students reported the course as excellent, with the remaining voting for "good." All participants agreed that the curriculum met expectations and would recommend it. Significant improvement in anastomosis attainment scores between days 1 and 3 (median score 4) and days 4 and 5 (median score 5) (W = 494.5, p = 0.00170). The frequency of errors reduced with successive attempts (chi square = 9.81, p = 0.00174). The steepest learning curve was in anastomosis and patency domains, requiring 11 attempts on average to reach proficiency. In total, 88.5% survey respondents could apply the skills learnt and 76.9% applied the skills learnt within 6 months. Key areas of improvement were identified from this evaluation, and actions to address them were implemented in the following programs. Robust evaluation of curriculum can be applied to microsurgery training demonstrating its efficacy in reducing surgical errors with an improvement in overall technical skills that can extend to impact clinical practice. It allows the identification of areas of improvement, driving the refinement of training programs.

Implementation and validation of a novel instrument for the grading of unexpected events in paediatric surgery: Clavien-Madadi classification.

Inconsistent definitions of complications and unexpected events have limited accurate analysis of surgical outcomes. Perioperative outcome classifications currently used for adult patients have limitations when used for children. A multidisciplinary group of experts modified the Clavien-Dindo classification to increase its utility and accuracy in paediatric surgery cohorts. Organizational and management errors were considered in the novel Clavien-Madadi classification, which focuses on procedural invasiveness rather than anaesthetic management. Unexpected events were prospectively documented in a paediatric surgery cohort. Results of the Clavien-Dindo and Clavien-Madadi classifications were compared and correlated with procedure complexity. Unexpected events were prospectively documented in a cohort of 17 502 children undergoing surgery between 2017 and 2021. The results of both classifications were highly correlated (ρ = 0.95), although the novel Clavien-Madadi classification identified 449 additional events (organizational and management errors) over the Clavien-Dindo classification, increasing the total number of events by 38 per cent (1605 versus 1158 events). The results of the novel system correlated significantly with the complexity of procedures in children (ρ = 0.756). Furthermore, grading of events > grade III according to the Clavien-Madadi classification showed a higher correlation with procedure complexity (ρ = 0.658) than the Clavien-Dindo classification (ρ = 0.198). The Clavien-Madadi classification is a tool for the detection of surgical and non-medical errors in paediatric surgery populations. Further validation in paediatric surgery populations is required before widespread use.

Research progress of failure and revision of unicompartmental knee arthroplasty

To conclude the failure factors of unicompartmental knee arthroplasty (UKA), and summarize the research progress of revision surgery. The literature on UKA at home and abroad in recent years was reviewed to summarize its risk factors, treatment methods, including the evaluation of bone loss, prosthesis selection, and surgical techniques. The factors inducing UKA failure mainly include improper indications, technical errors, and others. The application of digital orthopedic technology can reduce failures caused by surgical technical errors and shorten the learning curve. There are a variety of options for revision surgery after UKA failure, including polyethylene liner replacement, revision with UKA or total knee arthroplasty, with adequate preoperative evaluation prior to implementation. The biggest challenge in revision surgery is the management and reconstruction of bone defects. There is a risk of failure in UKA, which needs to be treated with caution and should be determined according to the type of failure.

Right Condylar Jugular Diverticulum: Contrast-enhanced Computed Tomography Findings of a Rare Anatomical Variant of Jugular Bulb.

This is the first description of condylar jugular diverticulum (CJD) by means of contrast-enhanced computed tomography scan in the medical literature. CJD is a rare anatomical variant of jugular bulb that should be known to avoid radiological and surgical errors and achieve an appropriate pre-surgical planning of skull base pathologies.

To the discussion of the problem of errors in neurosurgery. Literature review

Among all adverse perioperative events, medical error is one of the most serious, associated with possible complications for the patient, severe psychological trauma for the surgeon, and often with the involvement of the Investigative Committee in assessing the results of treatment. At the same time, among the researchers of this issue there is still no consensus on what exactly is meant by «medical error». In modern legal scientific publications, they often call for abandoning this term and using the concept of «negligence» for lawyers. It is all the more important in the professional community to define the concept of «medical error» and distinguish it from other undesirable events associated with the treatment of the patient. This review presents different approaches to the definition of the concepts of «medical error» and «surgical error», what is their main difference from iatrogenic, medical negligence, complications of surgery. Some classifications of errors in surgery are presented. The most common factors of surgical errors are identified, such as lack of competence and experience of the doctor, impaired interaction and communication of staff, excessive workload and fatigue, emergency operations, unusual patient anatomy, lack of necessary equipment and instruments. Using the example of neurosurgical practice, such errors as performing a craniotomy on the wrong side, surgery on the spine at the wrong level, leaving foreign bodies in the wound, and others are considered. In conclusion, the main measures for the prevention of errors in surgery in general and in neurosurgery in particular are described.

ASAP: A Semi-Autonomous Precise System for Telesurgery During Communication Delays

In remote, rural, and disadvantaged areas, telesurgery can be severely hindered by limitations of communication infrastructure. In conventional telesurgery, delays as small as 300ms can produce fatal surgical errors. To mitigate the effect of communication delays during telesurgery, we introduce a semi-autonomous system that decouples the user interaction from the robot execution. This system uses a physics-based simulator where a surgeon can demonstrate individual surgical subtasks, with immediate graphical feedback. Each subtask is performed asynchronously, unaffected by communication latency, jitter, and packet loss. A surgical step recognition module extracts the intended actions from the observed surgeon-simulation interaction. The remote robot can perform each one of these actions autonomously. The action recognition system leveraged a transfer learning approach that minimized the data needed during training, and most of the learning is obtained from simulated data. We tested this system in two tasks: fluid-submerged peg transfer (resembling bleeding events) and surgical debridement. The system showed robustness to delays of up to 5 seconds, maintaining a performance rate of 87% for peg transfer and 88% for debridement. Also, the framework reduced the completion time under delays by 45% and 11% during peg transfer and debridement, respectively.

Soft tissue related complications around anterior implants: commentary and clinical checklist.

Implant-based rehabilitation is a clinical challenge, especially in the esthetic area. Numerous factors influence the outcome of the rehabilitation; however, the two main factors are the bone and soft-tissue deficiencies at the intended implant site. Peri-implant soft tissue complications can arise from a combination of factors that can be summarized in two categories: diagnostic errors and surgical planning management errors. Most of the complications can be corrected after each step of the treatment and even after the delivery of the prosthetic restoration with adequate soft tissue management in order to give the patient an esthetically pleasing outcome. The aims of this article are: to present the current literature, to propose a clinical checklist that will guide clinicians in evaluating the prognosis of the treatment utilizing soft tissue grafting, to illustrate a case series partially employing the proposed clinical checklist. The proposed checklist could be helpful in evaluating the prognosis of the treatment utilizing only soft tissue grafting. In clinical cases, in which the prognosis is classified as good, soft tissue management could be a viable treatment option before attempting more radical procedures like implant removal.

Medical errors and patient safety: Strategies for reducing errors using artificial intelligence

Background: Medical errors remain a significant challenge in healthcare, contributing to adverse patient outcomes, increased costs, and extended hospitalizations. These errors encompass diagnostic inaccuracies, medication mistakes, surgical errors, and communication breakdowns. The global prevalence of medical errors underscores the urgent need for effective strategies to enhance patient safety. Aim: This article explores the role of Artificial Intelligence (AI) in reducing medical errors and improving patient safety. It aims to evaluate how AI technologies can mitigate various types of medical errors, and the challenges associated with their implementation. Methods: The study reviews current literature on AI applications in healthcare, focusing on diagnostic support, medication safety, surgical precision, and patient monitoring. It analyzes the effectiveness of AI-driven systems in reducing errors across different medical disciplines and examines the integration challenges, including ethical and regulatory concerns. Results: AI technologies, including machine learning algorithms and decision support systems, have demonstrated significant potential in enhancing diagnostic accuracy, preventing medication errors, and improving surgical outcomes. AI-driven systems have shown promising results in real-time patient monitoring, early detection of adverse events, and optimizing healthcare management. However, challenges related to data privacy, algorithm transparency, and integration into clinical workflows persist.

Rotational Issues in Total Knee Arthroplasty: Commentary on an article by Eugene S. Jang, MD, MS, et al.: "Reference Axes for Tibial Component Rotation in Total Knee Arthroplasty. Computed Tomography-Based Study of 1,351 Tibiae".

Commentary Internal malrotation of the prosthetic components has been the single most common surgical error associated with the advent of contemporary total knee arthroplasties. On the femoral side, malrotation was primarily the result of posterior-referencing instrument systems and symmetrical components. On the tibial side, the reasons for internal malrotation have been multiple: the 85% predominance of varus knee deformity, the overwhelming incidence of the medial approach, the interference of the tibial tuberosity and patellar tendon with the traditional tibial cutting guides, and the innate desire of the physician to cover the entire tibial surface with a prosthetic device that is rotated to cover the deeper posteromedial bone. This study clearly indicates the preference of the Berger or Insall techniques, which involve using the medial third of the tibial tuberosity as the ideal osseous anatomic reference1. This landmark is very reproducible, accessible, and reliable. It is, however, only an osseous landmark, which ignores the influence of the previously positioned femoral component and the impact of soft-tissue balancing on the entire total knee procedure. For a computer or robotic arthroplasty enthusiast, numerical choices such as this one are attractive. They do, however, only reflect averages and thus may be expected to produce average results. While this narrows the Gaussian distribution of error, it does not account for the wide variation of anatomic configurations seen in clinical practice. Also, the overwhelming majority of prosthetic components are symmetrical and the natural knee is asymmetrical. While we think in our minds that we are reproducing the natural knee, we are merely placing a symmetrical component in a neutral “sweet spot” on 3 axes with 6 degrees of freedom. The fairly recent advent of asymmetrical tibial components has radically reduced the incidence of internal tibial rotation, although they must still conform, to some degree, to the axes identified in this computed tomography (CT) study. A general principle of all arthroplasties is that one should take advantage of both osseous anatomic and ligamentous soft-tissue input at every step of the procedure. Since most knee arthroplasties are now performed with the femoral component being inserted first—hopefully rotated to be parallel to the transepicondylar axis—the input of the femoral component and the supporting ligaments have a greater influence on the kinematic outcome than any single average osseous anatomic landmark2. A traditional approach to this issue was to first apply the trial femoral component to the distal part of the femur, then use a “floating trial” that would, after putting the knee through a range of motion, define the preferred position of tibial rotation relative to the femur and the surrounding ligaments. A knee is not a hip, and performing these component positionings in isolation is folly. If a floating trial indicates that the tibia would favor a rotational position aligned with the medial third of the tibial tuberosity, and the osseous and soft-tissue markers agree, then there should be no issue. If the floating trial position does not align over the medial third of the tibial tuberosity, then one must not only search for the reason but probably reach an accommodation. In my experience, the osseous position would dominate in a varus knee because of the greater influence of the topography of the surfaces. In a valgus knee, the ligaments often have a higher level of influence and should be preferred. Berger’s choice of the axis, which was confirmed by this CT study, has stood the test of time, over a quarter of a century. Asymmetrical components have corrected the surgeon’s natural impulse for internal rotation. The enunciation and confirmation of the importance of these choices is the major contribution of this article.

An Overview of the Literature on Patient Safety Culture

The prevention of errors and negative consequences on patients associated with health care is referred to as patient safety. Healthcare has become more complex as new technologies, drugs, and treatments have become more widely available. Every year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), resulting in 2.6 million deaths worldwide. Many medical practices and healthcare risks are emerging as critical issues for patient safety, significantly increasing the burden of harm caused by unsafe care. There are numerous predictors, including safety and risk management, medication errors, fall risks, unsafe surgical care procedures, diagnostic errors, hospital-acquired infections, and diagnostic errors, all of which pose a risk to patient safety measures. The role of a nurse surrounds the complete analysis of the solemn issue associated with the well-being and safety culture. Nurses contribute to patient safety by remaining at patients' bedsides and interacting with their families and other healthcare professionals.

Xenograft bone-patellar tendon-bone ACL reconstruction: a case series at 20-year follow-up as proof of principle

PurposeACL reconstruction has a significant failure rate. To address the need for inexpensive strong tissue, a treatment process to “humanize” porcine tissue was developed and tested in primates and humans. This report describes the long-term outcomes from the first human clinical trial using a porcine xenograft ACL reconstruction device.MethodsThe study was performed with Z-Lig™ xenograft ACL device in 2003 as a pilot clinical feasibility study. This device was processed to slow its immune-mediated destruction by enzymatic elimination of α-gal epitopes and by partial crosslinking to slow the infiltration of macrophages into the biotransplant.ResultsTen patients underwent reconstruction with the Z-Lig™ device. Five of 10 patients failed due to subsequent trauma (n = 3), arthrofibrosis (n = 1), and surgical technical error (n = 1). One patient was lost to follow-up after the 12-year evaluation. Each remaining patient reported a stable fully athletic knee. Physical exams are consistent with a score of less than one on the ACL stability tests. MRIs demonstrate mature remodeling of the device. There is no significant degradation in patient-reported outcome scores, physical exams, or MRI appearance from 12 to 20-year follow-ups.ConclusionsThe studies in a small group of patients have demonstrated that implantation of porcine ligament bioprosthesis into patients with torn ACLs can result in the reconstruction of the bioprosthesis into autologous ACL that remains successful over 20 years. The possibility of humanizing porcine tissue opens the door to unlimited clinical material for tissue reconstructions if supported by additional clinical trials.Level of evidenceIV, case series.

'Critical circle of fundoplication' - A key concept towards creating identical, replicable and consistent fundoplication wraps.

There is a significant learning curve associated with laparoscopic Nissen's fundoplication, during which, complications due to surgical errors are more likely to occur. Moreover, length of the wrap, its situation on the lower esophagus and the points of the fundus brought together to create the wrap are arbitrary and as per the surgeon's judgement and estimation. This leads to a lot of variation in the wraps created, not only from surgeon to surgeon, but also from case to case for each individual surgeon. We propose a new concept of 'Critical Circle of Fundoplication' and the new approach to construct the fundoplication based on this concept, by application of which, a mathematically precise fundoplication can be created which is consistent, accurate and optimum. A total of 132 patients were operated based on the concept of 'Critical Circle of Fundoplication' between 2015 and 2020, of which 116 patients completed one year of follow-up and are included in the paper. The demographic characteristics, intraoperative findings and postoperative are described in detail. An additional average time of 10.5 minutes (range: 8-26 minutes) was required in the precise measurements and markings that were required by this approach. By application of the concept of 'Critical Circle of Fundoplication', precise, consistent and optimum wraps can be created. By eliminating the errors of structural construction and placement of the wrap, overall results can be improved.

Editors’ Introduction

Editors’ Introduction