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

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.

scholarly journals EP.WE.135Analysis of National Bariatric Surgery Related Clinical Incidents

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Islam Omar ◽  
Brijesh Madhok ◽  
Chetan Parmar ◽  
Omar Khan ◽  
Michael Wilson ◽  
...  
Keyword(s):  
Bariatric Surgery ◽  
Significant Proportion ◽  
Learning System ◽  
Left Behind ◽  
High Severity ◽  
The United Kingdom ◽  
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 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.

scholarly journals Current challenges for women in orthopaedics

2021 ◽  
Vol 2 (10) ◽  
pp. 893-899
Author(s):  
Maryam Ahmed ◽  
Laura C. Hamilton
Keyword(s):  
Patient Outcomes ◽  
Lessons Learned ◽  
Business Sector ◽  
Left Behind ◽  
Diversity And Inclusion ◽  
The World ◽  
Female Surgeons ◽  
The Common ◽  
The Uk ◽  
The Military

Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective. Cite this article: Bone Jt Open 2021;2-10:893–899.

scholarly journals P59 How COVID-19 influenced UK Burns Services: a national multicentred audit

BJS Open ◽  
2021 ◽  
Vol 5 (Supplement_1) ◽  
Author(s):  
Ryo Yoshimura ◽  
Georgina Phillips ◽  
Justin Wormald ◽  
Declan Collins ◽  
Ryo Yoshimura
Keyword(s):  
Service Evaluation ◽  
Lessons Learned ◽  
Descriptive Statistics ◽  
National Guidelines ◽  
Multiple Stakeholders ◽  
Clinic Management ◽  
The Uk ◽  
Second Wave ◽  
Patient Presentation ◽  
Learning Points

Abstract Introduction COVID-19 has affected national guidelines and availability of resources, resulting in different approaches to treating burns. This project aimed to identify changes to burns management in the UK during the “first wave” of COVID-19, and how the lessons learned can be applied to the current “second wave”. Methods Between 11th July-15th September, 18 burns services across the UK completed a MDT survey and contributed data on service evaluation. The MDT survey captured perspectives of multiple stakeholders and included changes to burns services, disruptions to supply chain, and service improvements resulting from COVID-19. Service evaluation data was collected retrospectively and prospectively on patients who received inpatient/outpatient treatment during COVID-19. Patients in the retrospective cohort were first seen by burns services between 6th-30th April (coinciding with the UK’s COVID-19 peak), and the prospective cohort were first seen between 30th April-15th September. Each cohort consisted of 10-20 patients per burns service. Service evaluation covered key areas of burns aetiology, referral pathway changes, patient presentation delays to tertiary services, patient management decisions, and outpatient dressing clinic management. Data from the MDT survey and the service evaluation were analysed by descriptive statistics and thematic analysis. Results The changes to burns services include delays in burn referrals, increase in conservative management, and increased use of telemedicine. Conclusion Across the UK, safe and effective burns care continued to be delivered despite difficulties from the pandemic. We hope the learning points identified in this study will be of use during the “second wave” of the pandemic.

Institutional developments, standards and river quality: a UK history and some lessons for industrialising countries

1996 ◽  
Vol 33 (3) ◽  
pp. 211-222 ◽  
Author(s):  
D. W. M. Johnstone ◽  
N. J. Horan
Keyword(s):  
Middle Ages ◽  
Aquatic Environment ◽  
Industrial Revolution ◽  
Integrated Management ◽  
Sewage Treatment ◽  
Lessons Learned ◽  
Process Manufacturing ◽  
Treatment And Disposal ◽  
The Uk ◽  
Developed World

From the middle ages until the early part of the nineteenth century the streets of European cities were foul with excrement and filth to the extent that aristocrats often held a clove-studded orange to their nostrils in order to tolerate the atmosphere. The introduction in about 1800 of water-carriage systems of sewage disposal merely transferred the filth from the streets to the rivers. The problem was intensified in Britain by the coming of the Industrial Revolution and establishment of factories on the banks of the rivers where water was freely available for power, process manufacturing and the disposal of effluents. As a consequence the quality of most rivers deteriorated to the extent that they were unable to support fish life and in many cases were little more than open sewers. This was followed by a period of slow recovery, such that today most of these rivers have been cleaned with many having good fish stocks and some even supporting salmon. This recovery has not been easy nor has it been cheap. It has been based on the application of good engineering supported by the passing and enforcement of necessary legislation and the development of suitable institutional capacity to finance, design, construct, maintain and operate the required sewerage and sewage treatment systems. Such institutional and technical systems not only include the disposal of domestic sewage but also provisions for the treatment and disposal of industrial wastewaters and for the integrated management of river systems. Over the years a number of institutional arrangements and models have been tried, some successful other less so. Although there is no universally applicable approach to improving the aquatic environment, many of the experiences encountered by the so-called developed world can be learned by developing nations currently attempting to rectify their own aquatic pollution problems. Some of these lessons have already been discussed by the authors including some dangers of copying standards from the developed world. The objective of this paper is to trace the steps taken over many years in the UK to develop methods and systems to protect and preserve the aquatic environment and from the lessons learned to highlight what is considered to be an appropriate and sustainable approach for industrialising nations. Such an approach involves setting of realistic and attainable standards, providing appropriate and affordable treatment to meet these standards, establishment of the necessary regulatory framework to ensure enforcement of the standards and provision of the necessary financial capabilities to guarantee successful and continued operation of treatment facilities.

Staying the distance: Transforming Latin pedagogy at the Open University

2019 ◽  
Vol 18 (1-2) ◽  
pp. 101-128
Author(s):  
Mair E. Lloyd ◽  
James Robson
Keyword(s):  
Cultural Context ◽  
Learning Experience ◽  
New Technology ◽  
Significant Proportion ◽  
Lessons Learned ◽  
Future Research ◽  
Open University ◽  
Ancient Rome ◽  
Positive Effects ◽  
Pedagogical Changes

Abstract Between 2000 and 2013, over 8,000 students studied the module Reading Classical Latin at the Open University, the United Kingdom’s largest distance education provider. But while many learners attained high grades, a significant proportion withdrew from study or failed the module. In 2015, the original module was replaced with a completely new course, Classical Latin: The Language of Ancient Rome. This article details the innovative ways in which new technology and pedagogical theory from Modern Foreign Language (MFL) learning were drawn on by the team designing this new module, resulting in a learning experience which gives greater emphasis to elements such as spoken Latin, the intrinsic pleasure of reading, and cultural context. The (largely positive) effects of these pedagogical changes on student success and satisfaction are subsequently analysed using a rich mix of qualitative and quantitative data. Finally, the authors reflect on lessons learned and the possibilities for future research and enhancement.

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

2021 ◽  
Author(s):  
Islam Omar ◽  
Brijesh Madhok ◽  
Chetan Parmar ◽  
Omar Khan ◽  
Michael Wilson ◽  
...  
Keyword(s):  
Bariatric Surgery ◽  
Lessons Learned

scholarly journals Why Protect Ancient Woodland in the UK? Rethinking the Ecosystem Approach

2020 ◽  
pp. 1-24
Author(s):  
Jona Razzaque ◽  
Claire Lester
Keyword(s):  
High Speed ◽  
Biodiversity Loss ◽  
Ecosystem Approach ◽  
Lessons Learned ◽  
Value Systems ◽  
Ancient Woodland ◽  
Forestry Practices ◽  
Regulatory Frameworks ◽  
Trade Offs ◽  
The Uk

Abstract Sites of ancient woodland in the United Kingdom (UK) are diminishing rapidly and the multifunctional forest management system with its fragmented approach fails effectively to protect such woodland. In the face of reports on the destruction of ancient woodland, the HS2 High-Speed train project in the UK signifies the extent of trade-offs among the key stakeholders. Such large infrastructure projects typically come with high environmental and social costs, including deforestation, habitat fragmentation, biodiversity loss, and social disruption. This article examines the protection of ancient woodland in the UK and assesses the challenges in applying the ecosystem approach, an internationally recognized sustainability strategy, in the context of such protection. A better understanding of the ecosystem approach to manage ancient woodland is critical for promoting sustainable forestry practices in the UK and informs the discussion in this article of the importance of conserving ancient woodland globally. Lessons learned from UK woodland policies and certification schemes include the need to have in place strong regulatory frameworks, introduce clear indicators, and recognize pluralistic value systems alongside economic considerations. The article concludes that the protection of ancient woodland in the UK requires distinct and strong laws that reflect multiple values of this resource, acknowledge the trade-offs among stakeholders, and adopt an inclusive approach to reduce power asymmetries.

Bariatric Surgery Worldwide 2013

2015 ◽  
Vol 25 (10) ◽  
pp. 1822-1832 ◽  
Author(s):  
L. Angrisani ◽  
A. Santonicola ◽  
P. Iovino ◽  
G. Formisano ◽  
H. Buchwald ◽  
...  
Keyword(s):  
Bariatric Surgery ◽  
Bariatric Surgery Worldwide
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