Analysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgery

Quality indicators will likely be used in comprehensive surgical quality assessment and improvement programs. Quality indicators are the actions equated with good quality of care. As a case example, bariatric surgery quality indicators were developed using evidence in the literature combined with formal expert opinion validation. Qualitative analysis was performed to identify the critical thematic issues surrounding development of these surgical quality indicators. Researchers identified five major thematic categories during the development process. These included feasibility in medical records (availability, ease of abstraction, and cost), the number of indicators developed (optimal number), the lack of evidence in the literature (weight on expert opinion), structural versus process indicators, and linkage to outcomes (need to demonstrate that adherence to indicators is associated with better outcomes). This project, using bariatric surgery as an example, uncovered important issues that need to be addressed when developing quality assessment and quality improvement programs for evaluating surgical quality. As quality indicators will likely be developed and used increasingly, future projects in this regard will benefit from these lessons.

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SP5.1.3 Analysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgery

British Journal of Surgery ◽

10.1093/bjs/znab361.113 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Islam Omar ◽

Brijesh Madhok ◽

Chetan Parmar ◽

Omar Khan ◽

Michael Wilson ◽

...

Keyword(s):

Bariatric Surgery ◽

Significant Proportion ◽

Lessons Learned ◽

Learning System ◽

Left Behind ◽

High Severity ◽

Nasogastric Tubes ◽

The Uk ◽

Bariatric Surgery Worldwide ◽

Learning Points

Abstract Background Hundreds of thousands of patient-safety clinical incidents are reported to the National Reporting and Learning System (NRLS) database in the UK every year. The purpose of this study was to identify bariatric surgery-related learning points from these incidents. Methods We analyzed bariatric surgery-related clinical incidents reported to the UK NRLS database between 01 April 2005 and 31st October 2020. The authors used their experience to identify learning themes and design a safety checklist. Results We identified 541 bariatric surgery-related clinical incidents in 58 different themes. Preoperative incidents represented 30.3% (N = 164), intraoperative 38.1% (N = 206), and postoperative accounted for 31.6% (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 commonly reported 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 commonly reported high severity theme was improper management of diabetes mellitus (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. Conclusion We identified 58 specific themes of bariatric surgery-related clinical incidents. We proposed specific recommendations for each incidents theme in addition to a bariatric safety checklist to help improve the safety of bariatric surgery worldwide.

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