In:
British Journal of Surgery, Oxford University Press (OUP), Vol. 108, No. Supplement_7 ( 2021-10-27)
Kurzfassung:
Hundreds of thousands of patient-safety clinical incidents are reported to the National Reporting and Learning System (NRLS) database in the United Kingdom (UK) every year. The purpose of this study was to identify bariatric surgery-related learning points from these incidents. Methods We analysed bariatric surgery-related clinical incidents reported to the UK NRLS database between 01 April 2005 and 31st October 2020. Results We identified 541 bariatric surgery-related clinical incidents in 58 different themes. Preoperative incidents represented 30.31% (N = 164), intraoperative 38.09% (N = 206), and postoperative accounted for 31.61% (N = 171). In terms of severity of incidents, (150;27.7%) were of high severity, whereas medium and low severity incidents were (244;45.1%) and (147;27.2%) respectively. The most common high severity theme was failure of thromboprophylaxis (50;9.2%). Intraoperative high severity incidents included 17 incidents of stapling of orogastric/nasogastric tubes or temperature probes, 8 missed needles, 8 broken graspers, and 6 incidents of band parts left behind. Postoperatively, the most common high severity theme was improper management of diabetes mellitus (DM) (35;6.5%). Medications errors represented a significant proportion of the medium severity incidents and included (26;4.8%) incidents of improper or missed prescription of routine medications and anticoagulants preoperatively and (45;8.3%) wrong prescriptions, dosage or prescribing of contraindicated medications postoperatively. Among the low severity themes identified there were (23;4.3%) incidents of postoperative diet problems, and (19;3.5%) patients listed for wrong procedures. Conclusion We identified 58 specific themes of bariatric surgery-related clinical incidents. Awareness of these themes should help to improve the safety of bariatric surgery worldwide.
Materialart:
Online-Ressource
ISSN:
0007-1323
,
1365-2168
DOI:
10.1093/bjs/znab308.022
Sprache:
Englisch
Verlag:
Oxford University Press (OUP)
Publikationsdatum:
2021
ZDB Id:
2006309-X
