Abstract:
BACKGROUND:Root cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical errors is essential for developing rescue mechanisms to prevent adverse outcomes. OBJECTIVE:Descriptive study to characterise intraoperative technical error-event patterns in successful laparoscopic procedures. METHODS:Events (injuries) identified during prior blinded analyses of 54 unedited recordings of bariatric laparoscopic procedures were subjected to a secondary review to determine the presumed underlying error mechanism. The recordings were obtained from one university-based bariatric collaborative programme, and represented consultant, fellow and shared trainee cases. RESULTS:Sixty-six events were identified in 38 recordings, while 16 videos showed no events. In 25 (66%) of the videos that showed events, additional measures such as haemostasis or suture repair were required. Common identified events were minor bleeding (n=39, 59%), thermal injury to non-target tissue (n=7, 11%), serosal tears (n=6, 9%). Common error mechanisms were 'inadequate use of force/distance (too much)' (n=20, 30%) and 'inadequate visualisation' during grasping/dissecting (n=6, 9%), 'inadequate use of force/distance (too much)' using an energy device (n=6, 9%), or during suturing (n=6, 9%). All events were recognised intraoperatively. CONCLUSIONS:Analysis of successful operations allowed the identification of numerous error-event sequences. Reviewing injury mechanisms can enhance surgeons' understanding of relevant errors. This error awareness may aid surgeons in preparing for cases, help avoid errors and mitigate their consequences. Thus, this approach may impact future surgical education and quality initiatives aimed at reducing surgical risks.
journal_name
BMJ Qual Safjournal_title
BMJ quality & safetyauthors
Bonrath EM,Gordon LE,Grantcharov TPdoi
10.1136/bmjqs-2014-003816subject
Has Abstractpub_date
2015-08-01 00:00:00pages
516-21issue
8eissn
2044-5415issn
2044-5423pii
bmjqs-2014-003816journal_volume
24pub_type
杂志文章abstract:INTRODUCTION:Adverse events (AEs) affect 3-12% of hospitalised patients. These are estimates from a labour-intensive chart review process,which is not feasible outside research. Clinical deterioration on the wards triggers a rapid response teams (RRTs) consult and can be used to identify an AE prospectively. OBJECTIVE...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2014-003833
更新日期:2015-12-01 00:00:00
abstract::People who are sick are often the most vulnerable in society. They frequently rely on caring and competent healthcare professionals and should and do have expectations of a safe and caring environment. In a recent unexpected adventure through the healthcare system, the organisation, professionalism, caring and compass...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2011-000235
更新日期:2011-11-01 00:00:00
abstract:BACKGROUND:Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis' typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boa...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2018-008291
更新日期:2019-03-01 00:00:00
abstract:BACKGROUND:Insulin is a high-risk medicine which may cause significant patient harm or death when given incorrectly. A 10-fold error in administered insulin dose commonly occurs when the abbreviation 'u' is used for 'units' and subsequently misinterpreted as a 'zero.' METHOD:A multidisciplinary working party was conve...
journal_title:BMJ quality & safety
pub_type: 杂志文章,多中心研究
doi:10.1136/bmjqs.2010.049668
更新日期:2011-07-01 00:00:00
abstract:OBJECTIVE:The goal of this study was to identify barriers and facilitators to the optimal management of critically ill children who present initially to community hospitals and how best to support the needs of front-line healthcare providers in these settings prior to transfer to the regional academic paediatric health...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2013-002070
更新日期:2014-06-01 00:00:00
abstract:OBJECTIVE:We sought to identify the characteristics of patients who experience medical emergency team calls in the radiology department (MET-RD) and the relationship between these characteristics and patient outcomes. DESIGN/PARTICIPANTS:Retrospective review of 111 inpatient MET-RD calls (May 2008-April 2010). SETTIN...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2011-000423
更新日期:2012-06-01 00:00:00
abstract::OBJECTIVE To evaluate the effects of a clinical pharmacist service on health-related quality of life (HRQL) and prescribing of drugs. METHODS A randomised controlled study was performed in two internal medicine wards. The intervention consisted of medication reviews with feedback to the physicians, drug treatment disc...
journal_title:BMJ quality & safety
pub_type: 杂志文章,随机对照试验
doi:10.1136/bmjqs.2009.039693
更新日期:2011-09-01 00:00:00
abstract:BACKGROUND:Community pharmacists are well positioned to support patients' minor ailments. The objective was to evaluate the clinical and humanistic impact of a minor ailment service (MAS) in community pharmacy compared with usual pharmacist care (UC). METHODS:A cluster randomised controlled trial was conducted. Interv...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2019-010608
更新日期:2020-11-01 00:00:00
abstract::Medical errors continue to occur despite multiple strategies devised for their prevention. Although many safety initiatives lead to improvement, they are often short lived and unsustainable. Our goal was to build a culture of patient safety within a structure that optimised teamwork and ongoing engagement of the healt...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2012-001011
更新日期:2013-05-01 00:00:00
abstract:OBJECTIVES:To determine whether the items on the Time Out and the Sign Out of the Surgical Safety Checklist are properly checked by operating room (OR) staff and to explore whether the number of checked items is influenced by the severity of the intervention and the use of the checklist as a memory tool during the Time...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2012-001634
更新日期:2013-08-01 00:00:00
abstract:INTRODUCTION:Intravenous medication errors persist despite the use of smart pumps. This suggests the need for a standardised methodology for measuring errors and highlights the importance of identifying issues around smart pump medication administration in order to improve patient safety. OBJECTIVES:We conducted a mul...
journal_title:BMJ quality & safety
pub_type: 杂志文章,多中心研究
doi:10.1136/bmjqs-2015-004465
更新日期:2017-02-01 00:00:00
abstract:BACKGROUND:We sought to investigate the formal and informal ways preregistration students from medicine, nursing, pharmacy and the allied healthcare professions learn about patient safety. METHODS:We drew on Eraut's framework on formal and informal acquisition of professional knowledge to undertake a series of phased ...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2013-001905
更新日期:2013-10-01 00:00:00
abstract:BACKGROUND:The safety-and-quality movement is now two decades old. Errors persist despite best efforts, indicating that there are entrenched overt and perhaps less explicit barriers limiting the success of improvement efforts. OBJECTIVES AND HYPOTHESES: To examine the perspectives of five groups of healthcare worker...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2011-051755
更新日期:2012-09-01 00:00:00
abstract:BACKGROUND:Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic err...
journal_title:BMJ quality & safety
pub_type: 杂志文章,评审
doi:10.1136/bmjqs-2011-000150
更新日期:2012-02-01 00:00:00
abstract:BACKGROUND:Relatively little is known about how scorecards presenting performance indicators influence medication safety. We evaluated the effects of implementing a ward-level medication safety scorecard piloted in two English NHS hospitals and factors influencing these. METHODS:We used a mixed methods, controlled bef...
journal_title:BMJ quality & safety
pub_type: 杂志文章,多中心研究
doi:10.1136/bmjqs-2012-001730
更新日期:2014-02-01 00:00:00
abstract:BACKGROUND:Interest in patient safety (PS) is growing exponentially, fuelled by epidemiological research unveiling the extent of unsafe care. However, there is little information about the frequency of harm in developing and transitional countries. To address this issue, the authors performed a study known as the Ibero...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs.2011.051284
更新日期:2011-12-01 00:00:00
abstract:AIM:To evaluate the effectiveness of a 'Do not interrupt' bundled intervention to reduce non-medication-related interruptions to nurses during medication administration. METHODS:A parallel eight cluster randomised controlled study was conducted in a major teaching hospital in Adelaide, Australia. Four wards were rando...
journal_title:BMJ quality & safety
pub_type: 杂志文章,随机对照试验
doi:10.1136/bmjqs-2016-006123
更新日期:2017-09-01 00:00:00
abstract:BACKGROUND:Existing evidence indicates that reducing nurse staffing and/or skill mix adversely affects care quality. Nursing shortages may lead managers to dilute nursing team skill mix, substituting assistant personnel for registered nurses (RNs). However, no previous studies have described the relationship between nu...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2018-008948
更新日期:2019-09-01 00:00:00
abstract:BACKGROUND:Patient and family engagement (PFE) in healthcare is an important element of the transforming healthcare system; however, the prevalence of various PFE practices in the USA is not known. OBJECTIVE:We report on a survey of hospitals in the USA regarding their PFE practices during 2013-2014. RESULTS:The resp...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2015-004006
更新日期:2016-03-01 00:00:00
abstract:OBJECTIVE:To examine the effectiveness and cost-effectiveness of the community pharmacy New Medicine Service (NMS) at 26 weeks. METHODS:Pragmatic patient-level parallel randomised controlled trial in 46 English community pharmacies. 504 participants aged ≥14, identified in the pharmacy when presenting a prescription f...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2018-009177
更新日期:2020-04-01 00:00:00
abstract:BACKGROUND:Advocates for quality and safety have called for healthcare that is patient-centred and decision-making that involves patients. OBJECTIVE:The aim of the paper is to explore the barriers and facilitators to patient-centred care in the hospital discharge process. METHODS:A qualitative study using purposive s...
journal_title:BMJ quality & safety
pub_type: 杂志文章,多中心研究
doi:10.1136/bmjqs-2012-001165
更新日期:2012-12-01 00:00:00
abstract:BACKGROUND:There is widespread recognition that leadership skills are essential for effective performance in the workplace, but the evidence detailing effective leadership behaviours for surgeons during operations is unclear. DATA SOURCES:Boolean searches of four on-line databases and detailed hand search of relevant ...
journal_title:BMJ quality & safety
pub_type: 杂志文章,评审
doi:10.1136/bmjqs.2010.040295
更新日期:2011-07-01 00:00:00
abstract:OBJECTIVE:To explore whether differences between collaboratives with respect to type of topic, type of targets, measures (systems) are also reflected in the degree of effectiveness. STUDY SETTING:182 teams from long-term healthcare organisation developed improvement initiatives in seven quality-improvement collaborati...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs.2010.047159
更新日期:2011-04-01 00:00:00
abstract:OBJECTIVE:To determine the quality and diagnostic accuracy of in-hospital adult clinical emergency calls. DESIGN:Prospective observational study. SETTING:Three National Health Service acute hospitals in England. PARTICIPANTS:Adult patients sustaining an in-hospital cardiac arrest (CA) or medical emergency (ME) which...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2011-000319
更新日期:2012-03-01 00:00:00
abstract:BACKGROUND:Learning is in delicate balance with safety, as faculty supervisors try to foster trainee development while safeguarding patients. This balance is particularly challenging if trainees are allowed to experience the educational benefits of failure, acknowledged as a critical resource for developing competence ...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2019-009808
更新日期:2020-09-01 00:00:00
abstract:OBJECTIVE:To assess quality of care for children presenting with acute abdominal pain using validated indicators. DESIGN:Audit of care quality for acute abdominal pain according to 21 care quality indicators developed and validated in four stages. SETTING AND PARTICIPANTS:Medical records of children aged 1-15 years r...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2019-010088
更新日期:2020-06-01 00:00:00
abstract:BACKGROUND:Interest in the use of social network analysis (SNA) in healthcare research has increased, but there has been little methodological research on how to choose the name generators that are often used to collect primary data on the social connection between individuals for SNA. OBJECTIVE:We sought to determine...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2011-000521
更新日期:2012-12-01 00:00:00
abstract:OBJECTIVES:To synthesise qualitative studies that investigated the experiences of healthcare professionals with using information from patient-reported outcome measures (PROMs) to improve the quality of care. DESIGN:A qualitative systematic review was conducted by searching PubMed, PsycINFO and CINAHL with no time res...
journal_title:BMJ quality & safety
pub_type: 杂志文章,评审
doi:10.1136/bmjqs-2013-002524
更新日期:2014-06-01 00:00:00
abstract::'The Problem with…' series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. ...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2017-007463
更新日期:2018-09-01 00:00:00
abstract:OBJECTIVES:To sustainably reduce the rate of mislabelled laboratory specimens through implementation of a series of interventions as led and coordinated by a multidisciplinary performance improvement team. METHODS:The quality improvement project was performed at Cedars-Sinai Medical Center in Los Angeles, an academic ...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2014-003005
更新日期:2014-08-01 00:00:00