Andrew Carson-Stevens

ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY: SURGICAL TECHNIQUE AND CLINICAL OUTCOMES AT 1 YEAR

1 Ho H, Schwentner C, Neururer R, Steiner H, Bartsch G, Peschel R. Robotic-assisted laparoscopic partial nephrectomy: surgical technique and clinical outcomes at 1 year. BJU Int 2009; 103 : 663–8 2 Hyams E, Mufarrij P, Stifelman M. Robotic renal and upper tract reconstruction. Curr Opin Urol 2008; 18 : 557–63 3 Melfi F, Mussi A. Robotically assisted lobectomy: learning curve and complications. Thorac Surg Clin 2008; 18 : 289–95 4 Pareja R, Ramirez P. Robotic radical hysterectomy in the management of gynecologic malignancies. J Minim Invasive Gynecol 2008; 15 : 673–6 5 Ellis W, Lange P. Point: open radical prostatectomy should not be abandoned. J Natl Compr Canc Netw 2007; 5 : 685–8 6 Sawa Y, Monta O, Matsuda H. Use of the Zeus robotic surgical system for cardiac surgery. Nippon Geka Gakkai Zasshi 2004; 105 : 726–31 7 Lendvay T, Casale P, Sweet R, Peters C. VR robotic surgery: randomized blinded study of the dV-Trainer robotic simulator. Stud Health Technol Inform 2008; 132 : 242–4

How safe is primary care? A systematic review

Importance Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care. Objective We investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm. Evidence review We searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised. Findings Nine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2–3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patients well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm. Conclusions and relevance Millions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm. Systematic review registration This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42012002304).

Safety incidents in the primary care office setting

BACKGROUND: In the United Kingdom, 26% of child deaths have identifiable failures in care. Although children account for 40% of family physicians’ workload, little is known about the safety of care in the community setting. Using data from a national patient safety incident reporting system, this study aimed to characterize the pediatric safety incidents occurring in family practice. METHODS: We undertook a retrospective, cross-sectional, mixed methods study of pediatric reports submitted to the UK National Reporting and Learning System from family practice. Analysis involved detailed data coding using multiaxial frameworks, descriptive statistical analysis, and thematic analysis of a special-case sample of reports. Using frequency distributions and cross-tabulations, the relationships between incident types and contributory factors were explored. RESULTS: Of 1788 reports identified, 763 (42.7%) described harm to children. Three crosscutting priority areas were identified: medication management, assessment and referral, and treatment. The 4 incident types associated with the most harmful outcomes are errors associated with diagnosis and assessment, delivery of treatment and procedures, referrals, and medication provision. Poor referral and treatment decisions in severely unwell or vulnerable children, along with delayed diagnosis and insufficient assessment of such children, featured prominently in incidents resulting in severe harm or death. CONCLUSION: This is the first analysis of nationally collected, family practice–related pediatric safety incident reports. Recommendations to mitigate harm in these priority areas include mandatory pediatric training for all family physicians; use of electronic tools to support diagnosis, management, and referral decision-making; and use of technological adjuncts such as barcode scanning to reduce medication errors.

Reducing the burden of iatrogenic harm in children

In 2013, as many as 6·3 million children worldwide died before their fifth birthday.1 Children have an increased risk of health-care-related harm because of factors including the complexity of prescribing and dispensing of drugs, a reduced physiological reserve compared with adults, and dependency on others (ie, parents and health-care providers) to recognise the emergence of a hazardous situation.2 Despite these factors, little research has been done of the contributions of substandard care and iatrogenic harm to deaths in childhood.

Harms from discharge to primary care: mixed methods analysis of incident reports

Background Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital. Aim To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice. Design and setting A mixed methods analysis of 598 patient safety incident reports in England and Wales related to ‘Discharge’ from the National Reporting and Learning System. Method Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice. Results A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with ‘safe discharge’ checklists, discharge coordinators, and family involvement. Conclusion Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.

Pediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database.

Background Children are scheduled to receive 18–20 immunizations before their 18th birthday in England and Wales; this approximates to 13 million vaccines administered per annum. Each immunization represents a potential opportunity for immunization-related error and effective immunization is imperative to maintain the public health benefit from immunization. Using data from a national reporting system, this study aimed to characterize pediatric immunization-related safety incident reports from primary care in England and Wales between 2002 and 2013. Methods A cross-sectional mixed methods study was undertaken. This comprised reading the free-text of incident reports and applying codes to describe incident type, potential contributory factors, harm severity, and incident outcomes. A subsequent thematic analysis was undertaken to interpret the most commonly occurring codes, such as those describing the incident, events leading up to it and reported contributory factors, within the contexts they were described. Results We identified 1745 reports and most (n = 1077, 61.7%) described harm outcomes including three deaths, 67 reports of moderate harm and 1007 reports of low harm. Failure of timely vaccination was the potential cause of three child deaths from meningitis and pneumonia, and described in a further 113 reports. Vaccine administration incidents included the wrong number of doses (n = 476, 27.3%), wrong timing (n = 294, 16.8%), and wrong vaccine (n = 249, 14.3%). Documentation failures were frequently implicated. Socially and medically vulnerable children were commonly described. Conclusion This is the largest examination of reported contributory factors for immunization-related patient safety incidents in children. Our findings suggest investments in IT infrastructure to support data linkage and identification of risk predictors, development of consultation models that promote the role of parents in mitigating safety incidents, and improvement efforts to adapt and adopt best practices from elsewhere, are needed to mitigate future immunization-related patient safety incidents. These priorities are particularly pressing for vulnerable patient groups.

A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice

Introduction Incident reports contain descriptions of errors and harms that occurred during clinical care delivery. Few observational studies have characterised incidents from general practice, and none of these have been from the England and Wales National Reporting and Learning System. This study aims to describe incidents reported from a general practice care setting. Methods and analysis A general practice patient safety incident classification will be developed to characterise patient safety incidents. A weighted-random sample of 12 500 incidents describing no harm, low harm and moderate harm of patients, and all incidents describing severe harm and death of patients will be classified. Insights from exploratory descriptive statistics and thematic analysis will be combined to identify priority areas for future interventions. Ethics and dissemination The need for ethical approval was waivered by the Aneurin Bevan University Health Board research risk review committee given the anonymised nature of data (ABHB R&D Ref number: SA/410/13). The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.

Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports

Background older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting. Objectives to describe the factors associated with actual or potential harm to patients aged 65 years and older, treated in primary care, to identify action to produce safer care. Design and Setting a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013. Subjects 1,591 primary care patient safety incident reports regarding patients aged 65 years and older. Methods we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care. Results the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serious patient harm outcomes (n = 203, 13%; 41% serious patient harm). Conclusion priority areas for further research to determine the burden and preventability of unsafe primary care for older adults, include: the timely electronic tools for prescribing, dispensing and administering medication in the community; electronic transfer of information between healthcare settings; and, better clinical decision-making support and guidance.

Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors

BackgroundOrthopaedic surgery is a high-risk specialty in which errors will undoubtedly occur. Patient safety incidents can yield valuable information to generate solutions and prevent future cases of avoidable harm. The aim of this study was to understand the causative factors leading to all unnecessary deaths in orthopaedics and trauma surgery reported to the National Patient Safety Agency (NPSA) over a four-year period (2005–2009), using a qualitative approach.MethodsReports made to the NPSA are categorised and stored in the database as free-text data. A search was undertaken to identify the cases of all-cause mortality in orthopaedic and trauma surgery, and the free-text elements were used for thematic analysis. Descriptive statistics were calculated based on the incidents reported. This included presenting the number of times categories of incidents had the same or similar response. Superordinate and subordinate categories were created.ResultsA total of 257 incident reports were analysed. Four main thematic categories emerged. These were: (1) stages of the surgical journey – 118/191 (62%) of deaths occurred in the post-operative phase; (2) causes of patient deaths – 32% were related to severe infections; (3) reported quality of medical interventions – 65% of patients experienced minimal or delayed treatment; (4) skills of healthcare professionals – 44% of deaths had a failure in non-technical skills.ConclusionsMost complications in orthopaedic surgery can be dealt with adequately, provided they are anticipated and that risk-reduction strategies are instituted. Surgeons take pride in the precision of operative techniques; perhaps it is time to enshrine the multimodal tools available to ensure safer patient care.

The WHO Surgical Safety Checklist – Junior doctors as agents for change

An innovation is defined as “an idea, practice, or objective perceived as new by an individual, a group, or an organization” and diffusion has been defined as “the process by which an innovation is communicated through certain channels over time among the members of a social system.”1 In this editorial, we highlight the continuing journey of the WHO surgical safety checklist from innovation to diffusion and the barriers associated with the latter part of the journey especially when junior doctors act as agents for change. The origins of the checklist date back to 1935when a long-range bomber designed by Boeing crashed during a competition. This accident resulted in the death of the most technically gifted pilot on board. A few pilots believed that this catastrophe was a result of a single pilot being forced to remember countless steps before take-off. Consequently, they designed a set of simple step-by-step checks for take-off, flight, landing and taxiing. This resulted in an accumulation of 1.8 million miles without an accident and the end of the war.2 Similarly, it was stipulated that medicine had entered a similar phase and substantial aspects of clinical practice were too complex for clinicians to carry them out reliably from memory alone. It was noted that surgery focused more on developing technical skills and paid less attention to human factors – organizational influences (climate, resource management, and policies) that impact supervisory processes (scheduling, training, and oversight), which in turn establish the preconditions (technological, teamwork, communication and leadership-related) that produce errors.3 Two other forces led to the genesis of the surgical checklist. The first was the enormous volume and burden of surgery – 234 million operations carried out globally with almost seven million patients having major complications and one million dying during or immediately following surgery every year.4 In England and Wales, the National Patient Safety Agency (NPSA) houses the Reporting and Learning System (RLS), a database of incidents of iatrogenic harm suffered by patients undergoing treatment in hospital. Data from 2008 reveal that 152,017 (15.5%) incidents can be found in the discipline of surgery.5 The second, and perhaps key driver, for bringing the checklist to life was the Safe Surgery Saves Lives campaign run by the World Health Organisation (WHO) which aimed to identify minimum standards of surgical care that can be universally applied across countries and settings. A core set of safety checks was identified in the form of a WHO Surgical Safety Checklist that could be used in any operating theatre environment.6 Each step on the checklist is simple, widely applicable, and measurable, and it has already been demonstrated that its use reduced death and major complications regardless of the