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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...

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Autores principales: 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
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2022
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.
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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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