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PubMed1988

[Conflicts from the viewpoint of the surgeon].

Media-related subjects of conflict include (1) the media's limited but major focus on information, sensation and entertainment; (2) information first published before research done; (3) journalistic eagerness to hide nothing and say everything; (4) permanent onesided praise of surgery creating high utopian expectations; (5) false, at least, exaggerated promises of more than medicine can justify; (6) extreme critics making personal accusations already upon suspicion of surgical errors; (7) stepmotherly treatment of surgical routine, its accomplishments and pressures.

Attitude of Health Personnel↗
PubMed2004

Doctors' duty to disclose error: a deontological or Kantian ethical analysis.

Medical (surgical) error is being talked about more openly and besides being the subject of retrospective reviews, is now the subject of prospective research. Disclosure of error has been a difficult issue because of fear of embarrassment for doctors in the eyes of their peers, and fear of punitive action by patients, consisting of medicolegal action and/or complaints to doctors' governing bodies. This paper examines physicians' and surgeons' duty to disclose error, from an ethical standpoint; specifically by applying the moral philosophical theory espoused by Immanuel Kant (ie. deontology). The purpose of this discourse is to apply moral philosophical analysis to a delicate but important issue which will be a matter all physicians and surgeons will have to confront, probably numerous times, in their professional careers.

Bioethical Issues↗
PubMed2005

Reducing errors in the operating room: surgical proficiency and quality assurance of execution.

Technical operative errors cause surgical operative morbidity and adversely affect the clinical outcome of patients. Surgical proficiency thus underpins good and safe practice. In this context, standardization of endoscopic surgical operations and their execution are essential for the procurement and maintenance of quality assurance in endoscopic surgical practice. There is no clash between individual- (surgical proficiency) and system-based defense systems in the prevention of surgical errors--both underpin safe surgical practice. Although more human factors and surgical research are needed, it is possible to formulate and adopt a surgical error reduction system for endoscopic operations based on standardization of operations, surgical operative proficiency, and human reliability assessment and its related clinical counterpart, observational clinical human reliability assessment.

Clinical Competence↗
PubMed2005

Accuracy of customized miniature stereotactic platforms.

In this study, a new system was evaluated for implanting deep-brain stimulators based on a one-piece platform for each trajectory customized from a preoperative planning image. During surgery, the platform is attached to skull-implanted posts that extend through the scalp. The platform acts as a miniature stereotactic frame to provide guidance for parallel cannulas as they are advanced through a burr hole to the target. Accuracy is determined from a postoperative CT. For each implantation, the distance between the position observed in the postoperative image and the position calculated relative to the platform from the preoperative image is our measure of error. Because this measure incorporates the surgical error of electrode anchoring, brain shift between preoperative and postoperative scanning, and error in the measurement of the position of the electrode in CT, it will tend to overestimate the true error. The mean error was 2.8 mm for 20 implantations. These data reflect favorably the accuracy of this system when compared with others.

Artifacts↗
PubMed2003

Responsiveness of the National Eye Institute Refractive Error Quality of Life instrument to surgical correction of refractive error.

OBJECTIVE: Refractive error and the means by which it is corrected may impact substantially on quality of vision and health-related quality of life in ways not captured adequately by standard measures of visual acuity. The goal of this analysis was to evaluate the responsiveness of the National Eye Institute Refractive Error Quality of Life (NEI-RQL) instrument to surgical correction of refractive error. DESIGN: Prospective, multicenter cohort study. PARTICIPANTS: The NEI-RQL, a 42-item measure with 13 scales, was self-administered by 185 patients before and after undergoing surgical correction of myopic or hyperopic refractive error. Preoperative and postoperative clinical information was collected, including refractive error and corrected visual acuity. METHODS: Differences between preoperative and postoperative NEI-RQL scores were examined. Responsiveness was assessed using the standardized response mean and the responsiveness statistic. We also compared scales using relative efficiency estimates. MAIN OUTCOME MEASURES: Changes in NEI-RQL scales (clarity of vision, expectations, near vision, far vision, diurnal fluctuations, activity limitations, glare, symptoms, dependence on correction, worry, suboptimal correction, appearance, and satisfaction with correction). RESULTS: For myopes and hyperopes combined, refractive surgical correction was associated with statistically significant (P<0.05) improvements in scores for 11 of 13 scales. The largest improvements, ranging from 26 to 58 points on the 0 to 100 possible score range, were seen in expectations, activity limitations, dependence on correction, appearance, and satisfaction with correction. Separate analysis of myopes and hyperopes revealed similar effects in the 2 groups. Baseline scores were found to be predictive of change after surgery. CONCLUSIONS: The NEI-RQL is responsive to changes in vision-targeted health-related quality of life resulting from keratorefractive surgery. This instrument may prove useful for evaluating the beneficial and adverse impacts of surgical and nonsurgical methods of refractive error correction.

Adult↗
PubMed2001

Early reoperation for perirectal abscess: a preventable complication.

PURPOSE: The aim of this study was to analyze failures in the operative management of perirectal abscesses resulting in early reoperation. METHODS: This was a retrospective case study of 500 consecutive patients who underwent 627 drainage procedures for a perirectal abscess. RESULTS: Forty-eight patients (7.6 percent of all drainage procedures) required reoperation within ten days of the original procedure. The main factors leading to reoperation were incomplete drainage (23 patients), missed loculations within a drained abscess (15 patients), missed abscesses (4 patients), and postoperative bleeding (3 patients). Incomplete drainage was more common with simple perirectal abscesses, whereas most overlooked collections were located posteriorly. Horseshoe abscesses were associated with a particularly high rate (50 percent) of operative failures. Neither preexisting perianal pathology nor systemic immunosuppressive disease contributed to early failures. CONCLUSION: Surgical errors are the leading cause of early failures in the surgical treatment of perianal abscesses. These errors occur in a limited number of typical patterns and can therefore be identified and taught with an aim to decrease their occurrence.

Abscess↗
PubMed1998

Errors enacted during endoscopic surgery--a human reliability analysis.

The aim of the study was to document the nature and incidence of surgical errors enacted during laparoscopic surgery in order to direct future research and surgical training. A modified Human Reliability Analysis (HRA) approach, based on direct observation, was adopted to categorise and record errors encountered during the practice of laparoscopic cholecystectomy. This study confirmed the applicability and usefulness of an observational methodology in the assessment of human error in endoscopic surgical performance. The study identified aspects of the design and usage of instruments, surgical training and the differences between tasks which needed further directed research in order to identify underlying performance shaping factors (PSFs) and so reduce error rates.

Cholecystectomy↗
PubMed1990

Are in-hospital deaths and long stay markers for errors in surgery?

To test the feasibility of using a system for classification of surgical errors and of in-hospital deaths and long hospital stay as markers for errors in surgery we reviewed the hospital records of 273 patients with 285 admissions. During the one year study period there were in all 3767 patients admitted for surgical care. From these we selected the 131 who died in the department during the year, the 100 who had the longest stay (greater than 33 days) and the 91 patients were referred to the departments of internal medicine, infectious diseases or orthopedic surgery. Errors were classified as error of omission or commission, in diagnosis or in therapy. Possible or definitive errors were found in the care of 23% of the patients who died and in 10% of the ones with a long hospital stay. Only 3% of patients referred to other departments experienced errors. It is concluded, that "in-hospital death and "long hospital stay" can be used as markers to identify errors in surgery.

Adolescent↗
PubMed1998

[Frontal extranasal glioma].

Extranasal gliomas are very rare tumours, being difficult to diagnose preoperatively due to the unspecific nature of symptoms and, at times, of the test. A newborn baby, prenatally diagnosed with frontal tumour, which on exploration showed a mass at the root of the nose, red-violet in colour and which seemed to become tenser. Skull x-ray and brain ultra-sound were normal. Ultra-sound of the tumour area and TAC showed a mass with solid content, with possible intracraneal communication. Faced with this possibility, removal by neurosurgical procedures was performed with no communications with SNC being observed. Histological diagnosis: extra-nasal glioma. Tumours situated at the root of the nose can have normal skin covering whose aspect is similar to the tumour mentioned above. Test carried out may not show accurately whether the tumour communicates with SNC or not, which may lead to surgical errors. We recommend that these malformations be treated directly by surgical teams which include neurosurgical specialists.

Diagnosis, Differential↗
PubMed1991

[Early angiographic assessment of coronary revascularizations using the internal mammary artery. Apropos of a consecutive and prospective series of 180 bypass grafts].

This report describes a consecutive and prospective series of 136 patients, who underwent coronary bypass using the internal mammary arteries. Coronary angiography was routinely performed on all patients 8 days after surgery. A total of 137 operations (1 reoperation) were performed on 180 coronary arteries using 132 left internal mammary arteries and 25 right internal mammary arteries. Direct bypass was performed 133 times (73.8%), sequential bypass 23 times (25.5%) and free graft once. Bypass involved 1 coronary artery 89 times (65.4%), 2 coronary arteries 46 times (33.8%) and 3 coronary arteries in 1 case. The overall early success rate of internal mammary bypass in this series was 94.8% including 2 bypasses which were patent but non-functional. Of the 23 sequential bypasses, only 1 anastomosis out of 46 was not patent for a success rate of 97.3%. These good results are attributed to the large diameter of the mammary artery. Early postsurgical imaging is valuable for several reasons. It allows detection of surgical errors and improvement of the procedure. It enables distinction between residual primary surgical stenosis and secondary stenosis or genuine restenosis. It allows analysis of perioperative complications allows. No correlations between myocardial infarction and bypass obstruction were found. Finally, it permits endoluminal therapies such as thrombolysis (1 case in this series) and dilatation (2 cases). In conclusion, although we do not perform angiography routinely, our policy is to perform imaging in all cases of postoperative complications and after certain procedures such as sequential bypass.

Anastomosis, Surgical↗
PubMed2005

Patient safety practices in the operating room: correct-site surgery and nothing left behind.

Not until the late 1990s, after the publication of the National Academy of Medicine's treatise "To Err Is Human," did safety standards specifically for patients begin to be considered in operating room practices. This report and other studies documented operating room mistakes including, for example, operations on the wrong hand or limb, operations on the wrong patient, and the performance of wrong procedures. Cases have also been documented of sponges or instruments being left by mistake inside patients following surgery. Poor communication is the most common root cause of errors. This article explores these issues and explains procedures and protocols developed to reduce surgical errors.

Female↗
PubMed2005

Video assisted thoracoscopic re-sympathetic surgery in the treatment of re-sweating hyperhidrosis.

OBJECTIVE: The characteristics and causes of re-sweating after sympathetic surgery in hyperhidrosis patients have yet to be clearly documented due primarily to low incidence of re-sympathetic surgery. The purpose of this study is to identify the causes of re-sweating following sympathetic surgery, and to assess the outcomes of re-sympathetic surgery. METHODS: From February 1997 to July 2003, 36 patients underwent re-sympathetic surgery in order to treat re-sweating. Patients originally underwent sympathetic surgery due to facial (14 cases), palmar (21 cases), and axillary (1 case) hyperhidrosis. RESULTS: Sympathectomy was performed as a primary surgical intervention in 7 cases (19.4%), sympathicotomy in 12 cases (33.3%), and sympathetic clipping in 17 cases (47.3%). Thirteen patients complained of re-sweating on both sides, and 23 patients exhibited unilateral re-sweating. The onset of re-sweating occurred after an average of 3.1+/-3.4 months (range, 1-12 months) after the operation. The causes of re-sweating after sympathetic surgery included an intact sympathetic chain in 4 cases (11.1%), incomplete resection in 6 cases (16.7%), partial reattachment in 6 cases (16.7%), improper ganglion location in 4 cases (11.1%), clip slipping out in 11 cases (30.5%), and unknown in 5 cases (13.9%). Twenty-seven patients (75.0%) exhibited re-sweating within 3 months, and 9 patients (25.0%) experienced re-sweating after 6 months. During the second operation, sympathicotomy was performed in 20 cases (55.6%) and sympathetic clipping in 16 cases (44.4%) in which 32 patients (88.9%) reported decreased sweating. CONCLUSIONS: Surgical errors during the initial operation constituted the main cause of re-sweating following sympathetic surgery. Re-sympathetic surgery was necessary in order to treat re-sweating, and was associated with favorable outcomes.

Adolescent↗
PubMed2006

Error reduction in surgical pathology.

CONTEXT: Because of its complex nature, surgical pathology practice is inherently error prone. Currently, there is pressure to reduce errors in medicine, including pathology. OBJECTIVE: To review factors that contribute to errors and to discuss error-reduction strategies. DESIGN: Literature review. RESULTS: Multiple factors contribute to errors in medicine, including variable input, complexity, inconsistency, tight coupling, human intervention, time constraints, and a hierarchical culture. Strategies that may reduce errors include reducing reliance on memory, improving information access, error-proofing processes, decreasing reliance on vigilance, standardizing tasks and language, reducing the number of handoffs, simplifying processes, adjusting work schedules and environment, providing adequate training, and placing the correct people in the correct jobs. CONCLUSIONS: Surgical pathology is a complex system with ample opportunity for error. Significant error reduction is unlikely to occur without a sustained comprehensive program of quality control and quality assurance. Incremental adoption of information technology and automation along with improved training in patient safety and quality management can help reduce errors.

Diagnostic Errors↗
PubMed1989

[Primary hyperparathyroidism. Apropos of 102 recent exploratory cervicotomies: diagnostic and clinical pitfalls].

The authors report on various diagnostic pitfalls on 102 patients having undergone exploratory cervicotomy for primary hyperparathyroidism. A false positive diagnostic error was made on 2% of the cases, bringing to 100 the number of patients with a confirmed diagnosis of primary hyperparathyroidism. False negative diagnosis was made on 4% of the patients: two late diagnoses leading to an acute toxic state and death postoperatively in both cases; two pure psychiatric variants leading to repetitive hospitalizations in psychiatry. Error in diagnosis because of a masking effect was made in 4% of the cases:--one association with a clear cell nephro--epithelioma--one association with a multiple myeloma--two associations with a benign monoclonal gammapathy. The absence of hypercalcemia, a diagnostic pitfall in the modern form of this disease was found in 7% of the cases. PTH hypersecretion which is virtually a constant finding in the normocalcemic form of the disease obviates in most cases the need of a bone biopsy and quantitative histomorphometric analysis. The association with another endocrinopathy was found in 12% of the cases (2 MEN I, 1 MEN II, 9 hyperthyroidism). Because of its high frequency in the aged (22% greater than 75 years) the diagnosis of this disease is difficult for its signs are mimicked as well by the aging process. The preoperative topographic diagnostic error is avoided since there doesn't seem to be any test which would preclude the normal surgical procedure of carefully exploring all 4 topographic sites of the parathyroid. Surgical errors can be numerous but minimized with the increasing experience of the operator. Histological errors are seen mainly in the normocalcemic variety where only electron microscopy can detect the typical signs of cellular hyperactivity.

Aged↗
PubMedDate not supplied

Intraoperative angiography.

The thromboendarterectomy can be improved with intraoperative angiography, sources of error may be considerably reduced. The control possibilities of intraoperative angiography offer advantages also for the various bypass operations as surgical errors can be found and corrected during the operation.

Aged↗
PubMed1999

Technical pitfalls of anterior cruciate ligament surgery.

Anterior cruciate ligament (ACL) reconstruction is extremely common. Although the number of primary reconstructions is increasing, failures and revision procedures continue to occur at approximately the same frequency. ACL reconstruction is a technically difficult procedure, and many failures can be attributed to surgical error. This article addresses the causes for failure of primary ACL reconstruction that lie within the surgeon's control. Preoperative assessment, surgical technique, and rehabilitation are addressed.

Anterior Cruciate Ligament↗
PubMed2006

Implant-retained overdenture design for the malpositioned mandibular implants.

In the rehabilitation of the edentulous mandible, implant-retained overdenture represents a viable and cost-effective treatment. Successful prosthetic integration of this treatment relies on the accurate 3-dimensional position and angulation of the implant fixtures. If these requirements are not fulfilled, implant malposition occurs and negative effects on the function, esthetics, and structural integrity of the prosthesis may follow. Implant malposition commonly results from poor planning, surgical error, inaccuracies in the radiographic/surgical template fabrication, and the instability of the template during surgery. Potential solutions for implant malposition include surgical re-treatment or prosthetic compensation in the form of an altered design of the final prosthesis. This article presents a prosthetic design of an overdenture for malpositioned implants in the anteroposterior plane. Prosthetic compensations included relocating the attachment mechanism into the bulk of the overdenture with the help of an interconnecting implant bar and a metal reinforcing framework for the overdenture.

Acrylic Resins↗
PubMed1993

A new method of analyzing vectors for changes in astigmatism.

This method of astigmatism analysis recognizes the need to define an astigmatism goal, thus allowing the surgeon to obtain precise, separate measures of the magnitude and the angle of surgical error. From this, the surgeon can evaluate what surgery may be required to achieve the initial preoperative goal. An index that measures surgical success is adjusted for the level of preoperative astigmatism. The resulting data allow statistical comparison of multiple surgeries and techniques. This method also assists in resolving the case when spectacle and corneal astigmatism do not coincide.

Astigmatism↗