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Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety
OBJECTIVES: The reporting of patient safety incidents (PSIs) occurring in minimally invasive thoracic surgery (MITS) is crucial. However, previous reports focused mainly on catastrophic events whereas minor events are often underreported. METHODS: All voluntary reports of MITS-related PSIs were retr...
Autores principales: | , , , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Oxford University Press
2022
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9419675/ https://www.ncbi.nlm.nih.gov/pubmed/35543477 http://dx.doi.org/10.1093/icvts/ivac129 |
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author | Bottet, Benjamin Rivera, Caroline Dahan, Marcel Falcoz, Pierre-Emmanuel Jaillard, Sophie Baste, Jean-Marc Seguin-Givelet, Agathe de la Tour, Richard Bertrand Bellenot, Francois Rind, Alain Gossot, Dominique Thomas, Pascal-Alexandre D’Journo, Xavier Benoit |
author_facet | Bottet, Benjamin Rivera, Caroline Dahan, Marcel Falcoz, Pierre-Emmanuel Jaillard, Sophie Baste, Jean-Marc Seguin-Givelet, Agathe de la Tour, Richard Bertrand Bellenot, Francois Rind, Alain Gossot, Dominique Thomas, Pascal-Alexandre D’Journo, Xavier Benoit |
author_sort | Bottet, Benjamin |
collection | PubMed |
description | OBJECTIVES: The reporting of patient safety incidents (PSIs) occurring in minimally invasive thoracic surgery (MITS) is crucial. However, previous reports focused mainly on catastrophic events whereas minor events are often underreported. METHODS: All voluntary reports of MITS-related PSIs were retrospectively extracted from the French REX database for ‘in-depth analysis’. From 2008 to 2019, we retrospectively analysed and graded events according to the WHO classification of PSIs: near miss events, no harm incidents and harmful incidents. Causes and corrective measures were analysed according to the human-technology-organization triad. RESULTS: Of the 5145 cardiothoracic surgery PSIs declared, 407 were related to MITS. Among them, MITS was performed for primary lung cancer in 317 (78%) and consisted in a lobectomy in 249 (61%) patients. PSIs were: near miss events in 42 (10%) patients, no harm incidents in 81 (20%) patients and harmful incidents in 284 (70%) patients (mild: n = 163, 40%; moderate: n = 78, 19%; severe: n = 36, 9%; and deaths: n = 7, 2%). Human factors represented the most important cause of PSIs with 267/407 (65.6%) cases, including mainly vascular injuries (n = 90; 22%) and non-vascular injuries (n = 43; 11%). Pulmonary arteries were the most affected site with 57/91 cases (62%). In all, there were 7 deaths (2%), 53 patients required second surgery (13%) and 30 required additional lung resection (7%). CONCLUSIONS: The majority of reported MITS -related PSIs were non-catastrophic. Human factors were the main cause of PSIs. Systematic reporting and analysis of these PSIs will allow surgeon and his team to avoid a large proportion of them. |
format | Online Article Text |
id | pubmed-9419675 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2022 |
publisher | Oxford University Press |
record_format | MEDLINE/PubMed |
spelling | pubmed-94196752022-08-29 Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety Bottet, Benjamin Rivera, Caroline Dahan, Marcel Falcoz, Pierre-Emmanuel Jaillard, Sophie Baste, Jean-Marc Seguin-Givelet, Agathe de la Tour, Richard Bertrand Bellenot, Francois Rind, Alain Gossot, Dominique Thomas, Pascal-Alexandre D’Journo, Xavier Benoit Interact Cardiovasc Thorac Surg Thoracic OBJECTIVES: The reporting of patient safety incidents (PSIs) occurring in minimally invasive thoracic surgery (MITS) is crucial. However, previous reports focused mainly on catastrophic events whereas minor events are often underreported. METHODS: All voluntary reports of MITS-related PSIs were retrospectively extracted from the French REX database for ‘in-depth analysis’. From 2008 to 2019, we retrospectively analysed and graded events according to the WHO classification of PSIs: near miss events, no harm incidents and harmful incidents. Causes and corrective measures were analysed according to the human-technology-organization triad. RESULTS: Of the 5145 cardiothoracic surgery PSIs declared, 407 were related to MITS. Among them, MITS was performed for primary lung cancer in 317 (78%) and consisted in a lobectomy in 249 (61%) patients. PSIs were: near miss events in 42 (10%) patients, no harm incidents in 81 (20%) patients and harmful incidents in 284 (70%) patients (mild: n = 163, 40%; moderate: n = 78, 19%; severe: n = 36, 9%; and deaths: n = 7, 2%). Human factors represented the most important cause of PSIs with 267/407 (65.6%) cases, including mainly vascular injuries (n = 90; 22%) and non-vascular injuries (n = 43; 11%). Pulmonary arteries were the most affected site with 57/91 cases (62%). In all, there were 7 deaths (2%), 53 patients required second surgery (13%) and 30 required additional lung resection (7%). CONCLUSIONS: The majority of reported MITS -related PSIs were non-catastrophic. Human factors were the main cause of PSIs. Systematic reporting and analysis of these PSIs will allow surgeon and his team to avoid a large proportion of them. Oxford University Press 2022-05-11 /pmc/articles/PMC9419675/ /pubmed/35543477 http://dx.doi.org/10.1093/icvts/ivac129 Text en © The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. https://creativecommons.org/licenses/by/4.0/This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. |
spellingShingle | Thoracic Bottet, Benjamin Rivera, Caroline Dahan, Marcel Falcoz, Pierre-Emmanuel Jaillard, Sophie Baste, Jean-Marc Seguin-Givelet, Agathe de la Tour, Richard Bertrand Bellenot, Francois Rind, Alain Gossot, Dominique Thomas, Pascal-Alexandre D’Journo, Xavier Benoit Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety |
title | Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety |
title_full | Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety |
title_fullStr | Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety |
title_full_unstemmed | Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety |
title_short | Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety |
title_sort | reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety |
topic | Thoracic |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9419675/ https://www.ncbi.nlm.nih.gov/pubmed/35543477 http://dx.doi.org/10.1093/icvts/ivac129 |
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