Meghan E. Garstka

Using simulation to improve root cause analysis of adverse surgical outcomes

OBJECTIVE The purpose of this study was to develop and test a simulation method of conducting investigation of the causality of adverse surgical outcomes. DESIGN Six hundred and thirty-one closed claims of a major medical malpractice insurance company were reviewed. Each case had undergone conventional root cause analysis (RCA). Claims were categorized by comparing the predominant underlying cause documented in the case files. Three cases were selected for simulation. SETTING All records (medical and legal) were analyzed. Simulation scenarios were developed by abstracting data from the records and then developing paper and electronic medical records, choosing appropriate STUDY PARTICIPANTS including test subjects and confederates, scripting the simulation and choosing the appropriate simulated environment. INTERVENTION In a simulation center, each case simulation was run 6-7 times and recorded, with participants debriefed at the conclusion. MAIN OUTCOME MEASURES Sources of error identified during simulation were compared with those noted in the closed claims. Test subject decision-making was assessed qualitatively. RESULTS Simulation of adverse outcomes (SAOs) identified more system errors and revealed the way complex decisions were made by test subjects. Compared with conventional RCA, SAO identified root causes less focused on errors by individuals and more on systems-based error. CONCLUSIONS The use of simulation for investigation of adverse surgical outcomes is feasible and identifies causes that may be more amenable to effective systems changes than conventional RCA. The information that SAO provides may facilitate the implementation of corrective measures, decreasing the risk of recurrence and improving patient safety.

Integrated Models of Education and Service Involving Community-Based Health Care for Underserved Populations: Tulane Student-Run Free Clinics

Objectives Throughout the United States numerous models of local programs, including student-run clinics, exist to address the issue of access to care. The role of these clinics in serving the local community and contributing to medical education has been documented only in limited detail, however. The purpose of this article is to describe the clinic models, patient demographics, and services provided by four student-run clinics in New Orleans. Methods This is a retrospective, multisite chart review study of adult patients examined at student-run clinics between January 1, 2010 and July 31, 2011. Results During a 19-month period, 859 patients collectively were seen at the clinics, for a total of 1455 visits. The most common reasons for seeking care were medication refills (21.6%) and musculoskeletal pain (12.0%). Counseling and health education were provided primarily for smoking cessation (9.0%), diabetes management (7.1%), and hypertension management (5.8%). Nearly one-fifth of patients were given a referral to primary care services. In the 2010–2011 academic year, 87.6% of preclinical medical students volunteered at ≥1 of these clinics and spent 4508 hours during 1478 shifts. Conclusions This article highlights the role of student-run clinics in the community, the safety-net healthcare system, and medical education. Future directions include the establishment of a new clinic, fundraising, and prospective studies to further assess the impact of student-run clinics.

A Tlx2-Cre mouse line uncovers essential roles for hand1 in extraembryonic and lateral mesoderm.

Hand1 regulates development of numerous tissues within the embryo, extraembryonic mesoderm, and trophectoderm. Systemic loss of Hand1 results in early embryonic lethality but the cause has remained unknown. To determine if Hand1 expression in extraembryonic mesoderm is essential for embryonic survival, Hand1 was conditionally deleted using the HoxB6‐Cre mouse line that expresses Cre in extraembryonic and lateral mesoderm. Deletion of Hand1 using HoxB6‐Cre resulted in embryonic lethality identical to systemic knockout. To determine if lethality is due to Hand1 function in extraembryonic mesoderm or lateral mesoderm, we generated a Tlx2‐Cre mouse line expressing Cre in lateral mesoderm but not extraembryonic tissues. Deletion of Hand1 using the Tlx2‐Cre line results in embryonic survival with embryos exhibiting herniated gut and thin enteric smooth muscle. Our results show that Hand1 regulates development of lateral mesoderm derivatives and its loss in extraembryonic mesoderm is the primary cause of lethality in Hand1‐null embryos. genesis 48:479–484, 2010.

Effectiveness of systems changes suggested by simulation of adverse surgical outcomes

Background Simulation of adverse outcomes (SAO) has been described as a technique to improve effectiveness of root cause analysis (RCA) in healthcare. We hypothesise that SAO can effectively identify unsuspected root causes amenable to systems changes. Methods Systems changes were developed and tested for effectiveness in a modified simulation, which was performed eight times, recorded and analysed. Results In seven of eight simulations, systems changes were effectively utilised by participants, who contacted anaesthesia using the number list and telephone provided to express concern. In six of seven simulations where anaesthesia was contacted, they provided care that avoided the adverse event. In two simulations, the adverse event transpired despite implemented systems changes, but for different reasons than originally identified. In one case, appropriate personnel were contacted but did not provide the direction necessary to avoid the adverse event, and in one case, the telephone malfunctioned. Conclusions Systems changes suggested by SAO can effectively correct deficiencies and help improve outcomes, although adverse events can occur despite implementation. Further study of systems concepts may provide suggestions for changes that function more reliably in complex healthcare systems. The information gathered from these simulations can be used to identify potential deficiencies, prevent future errors and improve patient safety.

Post-Operative Infections: Trends in Distribution, Risk Factors, and Clinical and Economic Burdens

BACKGROUND Post-operative infection (POI) is a serious complication in all surgical disciplines and can derail a patients treatment and recovery course. In this analysis, we examine national trends, risk factors, and costs associated with POI. METHODS Using the Nationwide Inpatient Sample (NIS) for the years available for data analysis at the time of this study (2003-2010), we performed a cross-sectional study of adult (≥18 years) inpatients with POI and designated Clinical Classification Software (CCS) procedural class codes for the operations performed. A comparison group was selected randomly from patients with the same CCS codes who underwent the same procedures but did not experience POI. As the NIS represents 20% of U.S. hospital admissions, excess cost and stay were calculated on the basis of the average difference between cost and duration of stay for POI cases and the cost and duration of stay for the comparison group, then extrapolated to estimate the national burden for the remaining 80% of stays nationwide. RESULTS Sample admissions included 139,652 cases of POI and 941,670 comparison subjects. The POIs were most common in procedures involving the digestive tract (46.5%), cardiovascular system (16.3%), or musculoskeletal system (11.2%). Older age, male gender, high Charlson Comorbidity Index Score (CCIS), and teaching, urban, or large hospitals were independent risk factors for POI in the multivariable model (p < 0.05). A POI was associated with a higher risk of death (odds ratio 2.93; 95% confidence interval 2.82-3.04, p < 0.001). Nationally, we estimate that POI resulted in an annual average of 1.04 million days of excess hospital stay and

Thyroid Surgery and Obesity: Cohort Study of Surgical Outcomes and Local Specific Complications

2.72 billion excess cost. CONCLUSIONS Identification of independent risk factors suggests areas for quality improvement initiatives. Post-operative infection carries substantial clinical and financial burdens in the United States, and further analysis of the associated costs is needed to identify areas for intervention to reduce this burden.

Can simulation improve the traditional method of root cause analysis: A preliminary investigation

INTRODUCTION Obesity is associated with numerous complications after elective general surgeries. The aim is to compare surgical outcomes and local specific complications in obese and non-obese patients after thyroid surgery. METHODS Retrospective study over a 3-year period at a North American academic institution. Outcome measures were operative time, estimated blood loss, hospital length of stay, and local specific complications (hypocalcemia, recurrent laryngeal nerve injury, wound hematoma, wound seroma, and chyle leakage). RESULTS A total of 469 patients were included (mean [SD] age, 50.11 [15.01] years; mean [SD] BMI, 30.5 [8.3] kg/m2; 207 [44.14%] obese). There was no difference in operative time (125.7 vs. 129.6, p = 0.52), estimated blood loss (16.88 vs. 14.56, p = 0.28), or hospital length of stay (0.95 vs. 0.95, p = 0.96). Overall, there was no difference in the rates of local specific complications between the two groups. CONCLUSIONS Obesity is not associated with adverse outcomes in patients undergoing thyroid surgery.