Wrong Site Research Articles

Eliminating Error in Central Line Scheduling and Placement Using Quality Improvement Methods.

The Joint Commission defines a sentinel event as "surgery or other invasive procedure performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for a patient regardless of the type of procedure or the magnitude of the outcome." At our institution, we observed a low but consistent rate of incorrect surgical line placement for pediatric patients with cancer. Following quality improvement methodology and using the resources available on a large academic medical campus we designed and implemented a new multi-factorial process to schedule and place surgical central lines for pediatric patients with cancer. Changes included re-defining responsibilities, adding staff, and redesigning the process with workflows supported by modifications to the electronic medical record. Our primary outcome measures were incorrect central line placement or near miss event per quarter and days between these events. After implementation the rate of incorrect line placement and near miss events was reduced to zero with 1018 days since the last incorrect line placement. As a result of our multi-factorial quality improvement initiative in the scheduling and placement of central lines, we were able to eliminate surgical line placement sentinel events and improve care for pediatric patients with cancer.

WP8.2 - Human Factors Analysis of CORESS cases using the NOTSS Framework

Abstract Aims Determine human factors implicated in cases submitted to the Confidential Reporting System in Surgery (CORESS), using the non-technical skills for surgeons (NOTSS) framework. Methods Consecutive cases submitted to CORESS, between 2005 and 2011 were evaluated as an interim analysis. The type of case, whether patient harm occurred, Clavien-Dindo (CD) classification, and the location of the incident were collected. Demographic data was not collected because they are often changed to protect patient identification. Each case was reviewed according to the non-technical skills for surgeons (NOTSS) taxonomy. Results There were 100 cases included in this interim analysis. The most common types of cases were delayed diagnosis (n=19), known complications (n=10), near misses (n=10), poor surgical technique (n=9), misuse of equipment/device (n=8), and wrong site surgery (n=5). Two-thirds of patients were harmed, with complications ranging from minor to life-threatening (9 CD I, 10 CD II, 32 CD III, 12 CD IV), and 4 resulting in death (CD V). Incidents occurred most frequently in the operating theatre (n=54), the ward (n=16), or the emergency department (n=9). There were 71 incidents that endangered patient safety related to deficiencies in situational awareness, 59 to poor communication and teamwork, 48 to poor decision-making, and 48 related to leadership failures. Conclusions The main human factors implicated in surgical patient safety incidents related to errors in situational awareness, communication and teamwork, and to a lesser extent, decision-making, and leadership. Efforts to prevent medical errors should be focused on clinician human factors training.

Wrong site but intact sight

Orbital foreign bodies are common. A large metallic foreign body involving ipsilateral orbit into the maxillary sinus is potentially vision-threatening. This case report describes a potentially serious incident involving a 49-year-old man who presented with an injury to his right eye with an iron nail while working in a factory. An iron nail penetrating the infraorbital margin of the right eye extended into the maxillary sinus associated with periorbital edema. X-ray showed a metallic foreign body extending from the right eye infraorbital margin into the maxillary sinus. Under local anesthesia, under all aseptic precautions, a linear iron nail measuring 4.5 cm in length was removed from the right orbit without any evidence of damage to vital structures. This case represents one of the largest reported infraorbital metallic (iron nail) foreign bodies, highlighting its rarity and potential danger to vision and overall health.

Intentional Insertion of Air to Predict the Diagnostic Accuracy of Stereotactic Biopsy and a Uniform Grading System for Reporting

Background and Objectives: Stereotactic biopsies are a relatively safe and reliable way of tissue diagnosis and characterization of eloquent area lesions/neoplasm. However, predicting the accuracy of the site of biopsy with the desired/planned site is not always possible. We describe a technique to identify the precise location of the biopsy site in the post-operative computed tomography (CT) scan using the injection of a low volume of air into the biopsy cannula. Methods: Hundred consecutive biopsies were performed in 80 adults/20 children (59 males/41 females, median age 51 years) over 3 years, consisting of 75 frameless and 25 frame-based stereotactic biopsies. After the biopsy specimens had been collected, a small volume of air (median 1 cc) was injected into the site. Post-operative CT was done within 4 hours of the biopsy to see the site of the air bubble, and the same was correlated with the histopathological accuracy. Results: Intra-cranial air in the selected target was present in 95 patients (Grade 1 and 2), while the air was seen in the track (Grade 3) in 3% and at an unrelated site (Grade 4) in 2% of cases. Both Grade 4 biopsies were negative on histopathology (diagnostic yield = 98%). Two negative biopsies were reported, which were both predicted with the Grade 4 biopsy. The grading allowed uniform reporting across series and eliminated the chance of upgrading/downgrading the report due to wrong site sampling within the lesion/neoplasm. Conclusion: The air-injection manoeuvre proposed for use in stereotactic biopsies of intra-cranial mass lesions is a safe and reliable technique that allows the exact biopsy site to be located without any related complications.

PENGISIAN SIGN IN DALAM MENINGKATKAN KEPATUHAN SAFE SURGERY DI RUMAH SAKIT PKU MUHAMMADIYAH YOGYAKARTA II

Background: Complications and deaths due to surgery become one of the global health problems. World Health Organization estimates that at least half a million deaths due to preventable surgical. An effort to improve the quality of surgical services including the Surgical Safety Checklist to use made by World Health Organization. Compliance to use this surgery checklist which is can increase the number of safe surgery,reduce the wrong site surgery and nearmiss.
 Method: This research is a qualitative action research design. The study population was all the doctors and nurse anesthetist. Number of samples 6 people. The data is collected by observation sheet Surgical Safety Checklist: Sign In RS PKU Muhammadiyah Yogyakarta Unit II for 3 cycles of observation.
 Result and Discussion: The results of observations on the first to the third cycle shows that all disobeying nurse anesthetist (100%) the Surgical Safety Checklist to fill: Sign In. The results of the response every cycle and a structured interview with the anesthesiologist showed that nurses are still confused how to use the checklist, the checklist has not been a necessity, the culture of patient safety is still minimal, lack quality of human resources, lack of supervision and lack of socialization mechanisms Surgical Safety Checklist noncompliance that influence nurses Sign In to to fill.
 Conclusion: Completing Sign In in the installation of surgery center in PKU Muhammadiyah Yogyakarta Unit II Hospital is noncompliance, because they still haven’t got the identity bracelet mounted on a patient who will be operating and marking the location of a rare surgery. Advice to hospital are to create a Standard Operating Procedure (SOP), SOP socialize regularly, make in-house training, increase the commitment of doctors and nurses, create a surveillance system, create a system of reward and punishment.

Circumferential digit marking to prevent inadvertent wrong site surgery or anesthetic administration

Circumferential digit marking to prevent inadvertent wrong site surgery or anesthetic administration

Urology never events in the United Kingdom: A retrospective 10‐year review

AbstractObjectivesThe aim was to assess the prevalence of never events (NEs) specific to urology in the United Kingdom and identify commonly occurring themes.MethodsData from the National Health Service (NHS) NEs website were obtained and all NEs from 2012 to 2022 were reviewed. Urology‐specific NEs were identified and further analysed in their respective categories. Data regarding the total number of surgical procedures performed in the NHS specific to each specialty were obtained via the NHS Hospital Episode Statistics website.ResultsThere were 3972 NEs recorded over the 10‐year period with 95 (2.4%) of these as a result of urology surgery. The most common surgical intervention associated with a urological NE was ureteric stenting, which comprised 45/95 (47.4%) of all analysed NEs. These consisted of wrong site ureteric stent insertion (n = 29), wrong site ureteric stent removal (n = 9), wrong stent type (n = 5) and retained guidewires (n = 2). There were 7.14 million urology surgeries performed in the 10‐year period, and prevalence was 0.0013%.ConclusionNEs are fully preventable serious incidents in the NHS. This is the first study to investigate the prevalence of NEs in urology in the United Kingdom. This study demonstrates that in the last 10 years the prevalence of urology NEs is low at 0.0013%, with ureteric stent procedures accounting for more than half of the NEs. Urologists should be mindful of the potential for wrong site surgery in urologic stenting procedures.

Novel Artificial Intelligence Tool for Real-time Patient Identification to Prevent Misidentification in Health Care.

Errors in the identification of true patients in a health-care facility may result in the wrong dose or dosage being given to the wrong patient at the wrong site during radiotherapy sessions, radiopharmaceutical administration, radiological scans, etc. The aim of this article is to reduce the error in the identification of correct patients by implementation of the Python deep learning-based real-time patient identification program. The authors utilized and installed Anaconda Prompt (miniconda 3), Python (version 3.9.12), and Visual Studio Code (version 1.71.0) for the design of the patient identification program. In the field of view, the area of interest is merely face detection. The overall performance of the developed program is accomplished over three steps, namely image data collection, data transfer, and data analysis, respectively. The patient identification tool was developed using the OpenCV library for face recognition. This program provides real-time patient identification information, together with the other preset parameters such as disease site, with a precision of 0.92%, recall rate of 0.80%, and specificity of 0.90%. Furthermore, the accuracy of the program was found to be 0.84%. The output of the in-house developed program as "Unknown" is provided if a patient's relative or an unknown person is found in restricted region. This Python-based program is beneficial for confirming the patient's identity, without manual interventions, just before therapy, administering medications, and starting other medical procedures, among other things, to prevent unintended medical and health-related complications that may arise as a result of misidentification.

The Relevance of World Health Organization Surgical Safety Checklist to Spinal Surgery

Across the 193 member states of the World Health Organization (WHO) an estimated 234 million operations were conducted worldwide in 2008 (1 per every 25 human beings on the planet). These numbers have continued to increase to 312.9 million by 2016. Surgical errors involving the wrong site, wrong procedure or wrong patient occur at a rate of 1 in 112,000. This equates to 2,000 estimated ‘never events’ every year with a significant associated physical and psychological burden on patients and surgeons and financial and reputational burden on health organisations involved in litigation for such errors. The WHO Surgical Safety Checklist (WHOSSC), produced in 2009 is now synonymous with safety in the operating theatre. This checklist imposes a process of scrutiny at the key steps of the patients journey through theatre. The key details scrutinised have been shown to improve patient outcomes and theatre efficiency. Several studies have looked at adapted checklists specific to different specialties and it is becoming clearer that whilst the overall benefit of the original checklist is undeniable, in some speciality areas a more deliberate and nuanced application of the checklist to address specific problems could be of value. As a specialism, spinal surgery differs from others with a significant risk of a perioperative complication leading to harm and morbidity, permanent disability or even death. Iatrogenic spinal cord injury requires high-level resources and prolonged, sometimes lifelong rehabilitation. Other complications include cerebrospinal fluid leak, blood loss, new neurologic deficit, hardware failure, proximal junctional failure, pseudarthrosis, and surgical site infection. Wrong level spinal surgery (WLSS) is a complication specific to spinal surgery and studies have reported WLSS effecting 50-68% of spinal surgeons at some point in their career. The risks of these complications can be mitigated by factors, some of which are included in the WHOSSC and others with are lacking. This scoping review looks at how surgical checklists; both the original and modified versions have and could be used to address the surgical safety challenges specific to spinal surgery.

A five-step approach to safer skin surgery

Background: Wrong site skin surgery is a never event with implications for patient well-being, in addition to potential medicolegal ramifications. There is no standardised approach to wrong site surgery (WSS) prevention in the United Kingdom. However, the World Health Organisation surgical checklist and NHS England's safety standards for invasive procedures (NatSSIP) have been useful in guiding the direction of change. Our experience: We describe our experience over the past decade, detailing five cases of WSS including three wrong site biopsies and two re-excisions of the wrong scar. Each provided a learning opportunity, identifying vulnerabilities in the skin surgery pathway. Our five-step approach to safer skin surgery: By reflecting on our experience, we created a simple five-step approach to safer skin surgery which could easily be adopted by other dermatology departments. This includes, developing a Standard operating procedure, requesting a surgical procedure, medical photography, in theatre, and education/governance. Our approach provides a step in the right direction for national standardisation of the skin surgery pathway.

Knowledge, Application and Practice of "Stop and Mock Before You Block" among Anaesthetic Doctors in Hospital Kuala Lumpur

Introduction : Safe practice during regional anaesthesia is important to ensure avoidance of morbidity and mortality. The Stop and Mock Before You Block is a safety initiative that is developed to prevent wrong sided and site regional blocks. The study aims to identify the incidences of wrong side or site blocks and also identify the knowledge, application and practice of anaesthetic doctors in Hospital Kuala Lumpur. Method : This is a observational descriptive study, where a questionnaire in the format of Google Form is distributed among Anaesthetic doctors via Whatsapp. The data was then collected and analysed using SPSS to generate frequencies and mean of responses. It was also used to analyse the relationship between the variables and demographics. Results : A total of 143 anaesthetic doctors responded. The study found an incidence of 8 wrongly performed blocks. The study also found significant correlation between years of practice and doctor’s grade to the knowledge, application and practice components. Conclusion : The study has identified 8 occurrences of wrong side or site block that has occurred among the anaesthetic doctors in Hospital Kuala Lumpur. Based on the results of the study, majority of the anaesthetic doctors had moderate to poor knowledge, application and practice of the Stop and Mock Before You Block safety initiative.

Single- and Multiple-Segment Percutaneous Pedicle Screw-Rod Fixation: Complications and Bailout Strategies

Percutaneous pedicle screw fixation systems have improved significantly since their introduction in 2001. A new surgeon’s learning curve is usually 70 cases when defined by the complication rate and not by a specific time to insertion. An appropriate preoperative assessment is important when considering a percutaneous pedicle screw approach, and high complication rates are linked to patients above the age of 65 and the need for multilevel fixation. A surgeon should be wary of performing surgery at the wrong site; therefore, meticulous documentation should be carried out, and the operative level should be confirmed. During surgery, attention should be paid to positioning the patient and varying the location of the skin incision depending on the patient’s obesity. Penetration of visceral structures and vessels due to guidewire insertion is not an uncommon complication. Anterior penetration of the guidewire by as little as 5 mm can cause significant sympathetic chain dysfunction. Guidewire removal should also be prevented during tapping of the screw hole and removal of the Jamshedi needle. This procedure has a high complication rate in unexperienced hands and should be performed by surgeons after adequate cadaver training. Surgeons should initially attempt only single-level fixations and then later on move to more complex multilevel fixations and deformity corrections.

The other side of capacitation: role of mouse male molecules in the regulation of time and place of capacitation.

Sperm capacitation is a necessary process for mammalian spermatozoa to acquire fertilization capability. This process occurs when the sperm enters the female's reproductive duct, involving a vital interplay with the uterine and oviductal environment, leading to morphological, physiological and biochemical modifications in the male gamete. Besides, for a successful sperm capacitation, molecules are incorporated onto the sperm's surface during its passage through the male reproductive tract followed by their subsequent removal. These molecules, referred to as decapacitation factors (DFs), also regulate capacitation, preventing this process from occurring in the wrong site or at the wrong time. While decapacitation factors have been extensively studied in recent decades in species such as Mus musculus, there is no comprehensive report consolidating information on all the identified decapacitation factors and the molecular basis of their function. The aim of this review is to summarize the data related to decapacitation factors discovered and characterized in Mus musculus. Concurrently, this review aims to elucidate the implications of different decapacitation factors throughout the fertilization process (i.e., capacitation, acrosomal reaction and fertilization), as well as the methodologies employed for their investigation. Given that mice (Mus musculus) have served as a valuable model in reproductive research due to their genetic similarity to humans, this review contributes to our understanding of the role of decapacitation factors in male fertility.

WTP6.8 A Decade of NHS Never Events – Has formal reporting made a difference?

Abstract Introduction NHS England defines “Never Events” (NE) as 'patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers'. NHS Organisations were required to publish data on NE from April 2012. This project aims to identify changes in NE patterns to help inform future learning. Methods All published data between April 2012 and March 2022 was collected from NHS England. Data processing and manipulation was carried out using Microsoft Excel. Results A total of n=4,055 NE and n=175,920,530 procedures were reported. During the 2020-2021 year there were significantly less (p=0.029) NE compared to 2019-2020, however the rate of NE per million procedures (25 vs 27) remained unchanged p=0.18. Overall, there appears to be an increasing trend in NE, p<0.001. The majority of NE related to wrong site surgery, n=1,628(40%), retained foreign objects, n=1,090(27%) and wrong implant/prosthesis, n=506(12%), p<0.001. Within wrong site surgery, the most common NE was wrong procedure, n=529(32%), followed by laterality errors, n=391(24%), p<0.001. Discussion & Conclusion The results demonstrate that despite systemic protective barriers such as the WHO Checklist, overall rate of NE has not reduced. This is likely to be confounded by changes in reporting as well as definitions, for example from April 2021 wrong tooth extraction was not considered a NE. The importance of Human Factors must not be overlooked, and NHS Trusts should consider formal provision of such training for all those in clinical roles.

Evaluating similarity measure for multimodal 3D to 2D registration

The 3D to 2D registration technique in spine surgery is vital to aid surgeons in avoiding the wrong site surgery by estimating the vertebral pose. The vertebral poses are estimated by generating the spatial correspondence relationship between pre-operative MR with intra-operative x-ray images, then evaluated using a similarity measure. Different similarity measures are used in 3D to 2D registration techniques to assess the spatial correspondence between the pre-operative and intra-operative images. However, to evaluate the registration performance of the similarity measures, the proposed framework employs three different similarity measures: Binary Image Matching, Dice Coefficients, and Normalized Cross-correlation technique to compare the images based on pixel positions. The registration accuracy of the proposed similarity measures is compared based on the mean Target Registration Error, mean Iteration Times, and success rate. In the absence of simulated test images, the experiment is conducted on the simulated AP and Lateral test images. The experiment conducted on the simulated test images shows that all three similarity measures work well for the feature based 3D to 2D registration in that BIM gives better results. The experiment also indicates high registration accuracy when the initial displacements are varied up to ±20 mm and ±100 of the translational and rotational parameters, respectively, for three similarity measures.

Surgical Marking Pen Contamination: Writing a Postoperative Infection Into Your Preoperative Plan.

Introduction Preoperative marking is an essential safety practice to prevent "never" events, including wrong site surgery. Moreover, the Joint Commission regulations of the Universal Protocol require that patients be marked to indicate the operative site. Marking typically occurs with a pen or marker, which may be disposable or reusable. Previous studies have demonstrated that methicillin-resistant Staphylococcus aureus (MRSA) can survive in the dark, moist, capped environment of the marking pen and thus could plausibly be a nidus for transmission from patient to patient. The Joint Commission has established no increased risk of postoperative infection with these markings. With this study, we aimed to determine the colonization of surgical marking pens in the plastic surgery population. Methods Two marking pens from five different attending plastic surgeons at a single institution were cultured in standard fashion for aerobic and anaerobic growth. All pens were used repeatedly in office settings for performing patient markings. Those same ten marking pens were then used to mark incision sites on mock patients. Standard povidone-iodine prepping was then performed in a paint-only fashion over the skin markings, and cultures were again taken. A control group consisted of cultures from five sterile pens from the operating room. Each sterile pen was opened, uncapped, and then swabbed. All twenty-five cultures were analyzed in the hospital laboratory in a blinded fashion. Results The five control pens revealed no bacterial growth. Of the 10 direct pen cultures, two samples grew coagulase-negative staphylococci and one culture contained Pseudomonas aeruginosa. The 10-patient marked and prepped specimens showed eight negative cultures and two with coagulase-negative staphylococci. Although Pseudomonas was detected on standard pen culture, no pseudomonal growth was present in any of the samples after patient marking and prepping with povidone-iodine. Conclusions Our findings reaffirm that marking pens may be vehicles for bacterial transmission and expand upon previous studies by describing the presence of bacterial colonization on marking pens even after surgical site preparation with povidone-iodine.

O167 A decade of NHS never events – has formal reporting made a difference?

Abstract Introduction NHS England defines “Never Events” (NE) as 'patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers’. NHS Organisations were required to publish NE data from April 2012. This project aims to identify changes in NE patterns to help inform training. Methods Published data between April 2012 and March 2022 was collected from NHS England. Data processing and manipulation was carried out using Microsoft Excel. Results A total of n=4,055 NE and n=175,920,530 procedures were reported. During the 2020-2021 year there were significantly less (p=0.029) NE compared to 2019-2020, however the rate of NE per million procedures (25 vs 27) remained unchanged p=0.18. Overall, there appears to be an increasing trend in NE, p<0.001. The majority of NE related to wrong site surgery, n=1,628(40%), retained foreign objects, n=1,090(27%) and wrong implant/prosthesis, n=506(12%), p<0.001. Within wrong site surgery, the most common NE was wrong procedure, n=529(32%), followed by laterality errors, n=391(24%), p<0.001. Conclusion The results demonstrate that despite systemic protective barriers such as the WHO Checklist, overall rate of NE has not reduced. This is likely to be confounded by changes in reporting as well as definitions, for example from April 2021 wrong tooth extraction was not considered a NE. The importance of Human Factors must not be overlooked, and NHS Trusts should consider formal provision of such training for all those in clinical roles.

MP06-20 SIGNIFICANT REDUCTION OF PERIOPERATIVE SERIOUS REPORTABLE EVENTS THROUGH A NOVEL SURGICAL SAFETY CHECKLIST AND TIME-OUT PROCEDURE

You have accessJournal of UrologyCME1 Apr 2023MP06-20 SIGNIFICANT REDUCTION OF PERIOPERATIVE SERIOUS REPORTABLE EVENTS THROUGH A NOVEL SURGICAL SAFETY CHECKLIST AND TIME-OUT PROCEDURE Nicole Alavi-Dunn, Amy Murray, Ella Echavez, Michael Ander, Kevin Smith, Vrusha Shastri, Anne Murphy, and Christopher Gonzalez Nicole Alavi-DunnNicole Alavi-Dunn More articles by this author , Amy MurrayAmy Murray More articles by this author , Ella EchavezElla Echavez More articles by this author , Michael AnderMichael Ander More articles by this author , Kevin SmithKevin Smith More articles by this author , Vrusha ShastriVrusha Shastri More articles by this author , Anne MurphyAnne Murphy More articles by this author , and Christopher GonzalezChristopher Gonzalez More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Loyola University Medical Centertab is an academic quaternary medical center in a large metropolitan area which saw a significant increase in serious reportable events (SRE) during calendar year (CY) 2021. SREs are defined by the National Quality Forum; those relating to the operating room (OR) include wrong site, wrong procedure, wrong patient, OR fire, and retained foreign object (RFO). We describe an interprofessional and multidisciplinary effort which resulted in a novel surgical safety checklist (SSC) and robust time-out procedure to reduce SREs. METHODS: Action plans from root cause analyses of OR SREs and assessment of near misses led to the development of a perioperative safety steering committee. Anesthesiology, Nursing, and Surgery departments participated, which included all faculty, residents, fellows, advanced practice nurses, and staff. The team developed a new time-out process incorporating visual aids to improve SSC adherence. SSC comprises 1) pre-induction check-in, 2) time out prior to start of case, 3) check out (debrief) prior to closure. Checklist compliance was routinely audited. Tri-annual interprofessional and multidisciplinary conferences and instructional sessions were held. Education included the importance of reporting near misses, safety related incidents, behavioral issues; and audit compliance with serious safety event (SSE) and SRE prevention. OR safety event and near miss reporting was tracked. RESULTS: In CY 2021 19,713 total cases were performed at the main OR (13,248) and the ambulatory surgery center (ASC) (6,465). Ten SREs occurred: 5 wrong site surgeries, 2 OR fires, 2 wrong procedures, and 1 air embolism. The new SSC/time-out procedure was implemented in early January of 2022. In CY 2022 through September 14, 275 cases were performed at main OR (9664) and ASC (4611). Two safety events occurred: one SRE (wrong site anesthesia block), and one SSE (intentionally RFO which was identified before leaving the operating room yet required re-exploration). CY 2021 perioperative near miss reports were 534, compared to 425 for CY 2022 through September. CY 2021 incident reporting events were 1301, which increased to 1893 for CY 2022 through September. CONCLUSIONS: Implementation and compliance with a surgical safety checklist/time-out procedure, regular interprofessional and multidisciplinary meetings for education and compliance updates, and increased safety incident reporting decreased SREs by 80% over a nine-month period. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e61 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicole Alavi-Dunn More articles by this author Amy Murray More articles by this author Ella Echavez More articles by this author Michael Ander More articles by this author Kevin Smith More articles by this author Vrusha Shastri More articles by this author Anne Murphy More articles by this author Christopher Gonzalez More articles by this author Expand All Advertisement PDF downloadLoading ...

Factors contributing to preventing operating room “never events”: a machine learning analysis

BackgroundA surgical “Never Event” is a preventable error occurring immediately before, during or immediately following surgery. Various factors contribute to the occurrence of major Never Events, but little is known about their quantified risk in relation to a surgery’s characteristics. Our study uses machine learning to reveal and quantify risk factors with the goal of improving patient safety and quality of care.MethodsWe used data from 9,234 observations on safety standards and 101 root-cause analyses from actual, major “Never Events” including wrong site surgery and retained foreign item, and three random forest supervised machine learning models to identify risk factors. Using a standard 10-cross validation technique, we evaluated the models’ metrics, measuring their impact on the occurrence of the two types of Never Events through Gini impurity.ResultsWe identified 24 contributing factors in six surgical departments: two had an impact of > 900% in Urology, Orthopedics, and General Surgery; six had an impact of 0–900% in Gynecology, Urology, and Cardiology; and 17 had an impact of < 0%. Combining factors revealed 15–20 pairs with an increased probability in five departments: Gynecology, 875–1900%; Urology, 1900–2600%; Cardiology, 833–1500%; Orthopedics,1825–4225%; and General Surgery, 2720–13,600%. Five factors affected wrong site surgery’s occurrence (-60.96 to 503.92%) and five affected retained foreign body (-74.65 to 151.43%): two nurses (66.26–87.92%), surgery length < 1 h (85.56–122.91%), and surgery length 1–2 h (-60.96 to 85.56%).ConclusionsUsing machine learning, we could quantify the risk factors’ potential impact on wrong site surgeries and retained foreign items in relation to a surgery’s characteristics, suggesting that safety standards should be adjusted to surgery’s characteristics based on risk assessment in each operating room. .Trial registration numberMOH 032-2019.

A novel edge-marking method in pleural covering with video-assisted thoracic surgery.

Total pleural covering is implemented to reinforce the visceral pleura with surgical sheets. It has been adopted for diffuse cystic lung diseases such as lymphangioleiomyomatosis to prevent pneumothorax and has achieved good results. The procedure is technically demanding, because it is difficult to cover the entire visceral pleura without disarrangement and jamming of surgical sheets, especially during thoracoscopic surgery, where grasping of a wrong site might happen when unfolding the sheets. Herein, we report a technique to cover the entire pleura with dotted line folded sheets to ease the thoracoscopic procedure. We found that the use of this marking method made the procedure easier, with just a little ingenuity, because marking the edges of sheets with dashed lines clarifies the site that should be grasped, thus preventing the incidence of grasping the wrong part of the sheet. Pleural covering with dotted line folded surgical sheets is a useful method for reduced port thoracoscopic surgery.