Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.

Abstract Background: The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.Methods: This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: “Patient”, “Tasks”, “Individual staff”, “Team”, “Work environment”, and “Management and Institutional context”. Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.Results: In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.Conclusion: A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

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Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

Patient Safety in Surgery ◽

10.1186/s13037-020-00261-7 ◽

2020 ◽

Vol 14 (1) ◽

Cited By ~ 1

Author(s):

Kholoud Houssaini ◽

Oumayma Lahnaoui ◽

Amine Souadka ◽

Mohammed Anass Majbar ◽

Abdelilah Ghannam ◽

...

Keyword(s):

Liver Resection ◽

Root Cause Analysis ◽

Team Work ◽

Contributing Factors ◽

Cause Analysis ◽

Resource Limitations ◽

Root Cause ◽

Contributory Factors ◽

Safety Interventions ◽

Individual Participant

Abstract Background The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA. Methods This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: “Patient”, “Tasks”, “Individual staff”, “Team”, “Work environment”, and “Management and Institutional context”. Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases. Results In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication. Conclusion A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

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Patterns Contributing to Severe Complications After Liver Resection: An Aggregate Root Cause Analysis of a Prospective Cohort

10.21203/rs.3.rs-42879/v1 ◽

2020 ◽

Author(s):

Kholoud Houssaini ◽

Oumayma Lahnaoui ◽

Amine Souadka ◽

Mohamed-Anass Majbar ◽

Abdelilah Ghannam ◽

...

Keyword(s):

Liver Resection ◽

Root Cause Analysis ◽

Team Work ◽

Cause Analysis ◽

Resource Limitations ◽

Root Cause ◽

Contributory Factors ◽

Liver Resections ◽

Safety Interventions ◽

Individual Participant

Abstract Background The Aggregate Root Cause Analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection (SC) using an AggRCA. Methods This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications (SC). All consecutive SC (Clavien-Dindo > 3a within the first 90 days after liver resection) that occurred between January 1st, 2018 and December 31st, 2019 were identified from a prospective electronic database and included in an AggRCA. This included a structured MMR (Morbidity and Mortality Review) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: “Patient”, “Tasks”, “Individual staff”, “Team”, “Work environment”, and “Management and Institutional context”. Data resulting from individual-participant RCA of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases. Results Among 105 consecutive liver resections, 15 cases (14.3%) including 5 deaths (4.8%) met the inclusion criteria. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication. Conclusion A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to SC lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

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Correction to: Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

Patient Safety in Surgery ◽

10.1186/s13037-020-00268-0 ◽

2020 ◽

Vol 14 (1) ◽

Author(s):

Kholoud Houssaini ◽

Oumayma Lahnaoui ◽

Amine Souadka ◽

Mohammed Anass Majbar ◽

Abdelilah Ghannam ◽

...

Keyword(s):

Liver Resection ◽

Root Cause Analysis ◽

Contributing Factors ◽

Cause Analysis ◽

Root Cause

An amendment to this paper has been published and can be accessed via the original article.

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Mass School Shootings in the United States: A Novel Root Cause Analysis Using Lay Press Reports

Clinical Pediatrics ◽

10.1177/0009922819873650 ◽

2019 ◽

Vol 58 (13) ◽

pp. 1423-1428 ◽

Cited By ~ 2

Author(s):

Chris A. Rees ◽

Lois K. Lee ◽

Eric W. Fleegler ◽

Rebekah Mannix

Keyword(s):

United States ◽

Environmental Factors ◽

Root Cause Analysis ◽

The United States ◽

School Shootings ◽

Contributing Factors ◽

Mass Shootings ◽

Cause Analysis ◽

Factors Associated ◽

Root Cause

School shootings comprise a small proportion of childhood deaths from firearms; however, these shootings receive a disproportionately large share of media attention. We conducted a root cause analysis of 2 recent school shootings in the United States using lay press reports. We reviewed 1760 and analyzed 282 articles from the 10 most trusted news sources. We identified 356 factors associated with the school shootings. Policy-level factors, including a paucity of adequate legislation controlling firearm purchase and ownership, were the most common contributing factors to school shootings. Mental illness was a commonly cited person-level factor, and access to firearms in the home and availability of large-capacity firearms were commonly cited environmental factors. Novel approaches, including root cause analyses using lay media, can identify factors contributing to mass shootings. The policy, person, and environmental factors associated with these school shootings should be addressed as part of a multipronged effort to prevent future mass shootings.

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Independent root-cause analysis of contributing factors, including dismantling of 2 duodenoscopes, to investigate an outbreak of multidrug-resistant Klebsiella pneumoniae

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2019.05.016 ◽

2019 ◽

Vol 90 (5) ◽

pp. 793-804 ◽

Cited By ~ 16

Author(s):

Arjan W. Rauwers ◽

Annet Troelstra ◽

Ad C. Fluit ◽

Camiel Wissink ◽

Arjo J. Loeve ◽

...

Keyword(s):

Klebsiella Pneumoniae ◽

Root Cause Analysis ◽

Multidrug Resistant ◽

Contributing Factors ◽

Cause Analysis ◽

Root Cause

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A qualitative content analysis of retained surgical items: learning from root cause analysis investigations

International Journal for Quality in Health Care ◽

10.1093/intqhc/mzaa005 ◽

2020 ◽

Vol 32 (3) ◽

pp. 184-189

Author(s):

Peter D Hibbert ◽

Matthew J W Thomas ◽

Anita Deakin ◽

William B Runciman ◽

Andrew Carson-Stevens ◽

...

Keyword(s):

Content Analysis ◽

Situational Awareness ◽

Qualitative Content Analysis ◽

Root Cause Analysis ◽

Public Health Services ◽

Contributing Factors ◽

Cause Analysis ◽

Root Cause ◽

Great Root ◽

The Impact

Abstract Objective To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. Design A qualitative content analysis of root cause analysis investigation reports. Setting Public health services in Victoria, Australia, 2010–2015. Participants Incidents of retained surgical items as described by 31 root cause analysis investigation reports. Main Outcome Measure(s) The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. Results Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. Conclusion Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.

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Going Down the Tubes: A Multidisciplinary Root Cause Analysis on a Patient Safety Event Involving Delayed Transfusions

Blood ◽

10.1182/blood-2019-123386 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 4988-4988

Author(s):

Yuho Ono ◽

Pamela Stravitz ◽

Yael Heher ◽

Monique Mohammed ◽

Kerry O'Brien ◽

...

Keyword(s):

Patient Safety ◽

Conflicts Of Interest ◽

Multiple Root ◽

Root Cause Analysis ◽

Blood Products ◽

Contributing Factors ◽

Cause Analysis ◽

Root Cause ◽

Safety Event ◽

Reliable Performance

Background The pneumatic tube delivery system (PTDS) has been an integral part of blood bank (BB) operations at our institution ever since its implementation in the early 2000s. Its reliable performance is essential for rapid and accurate delivery of blood products, impacting patient safety and product integrity. However, malfunctioning operational events are not uncommon given PTDS complexity and hospital-wide utilization. In 2018, 33 of 285 (12%) blood products were wasted due to PTDS events at our institution. Here we review the root cause analysis (RCA) of a patient safety event involving delayed transfusions and a wasted blood product causing temporary harm to two patients. Methods Two patients, both hospitalized on the same floor, simultaneously experienced significant delays in red blood cell (RBC) transfusions. One patient with active bleeding experienced a 2-hour delay and another patient with anemia experienced a 50-minute delay before appropriate transfusion occurred. The two patients did not receive their transfusions until their nurses physically retrieved RBC units from the BB. An incident report was filed by a floor nurse, which prompted a RCA involving the laboratory quality and patient safety team, the BB, the hospital maintenance department overseeing the PTDS, and the information systems service controlling programming of the PTDS. Results Operational challenges surrounding the PTDS were central to the multiple root causes identified (see Table). RBC units sent to the floor from the BB were electronically directed to another floor or returned to the BB, which resulted in a waste of one RBC unit. Despite multiple potential contributing factors identified, deeper investigation did not uncover evidence for any specific root cause and the electronic tube transaction history showed normal PTDS operations during the time of the incident, with all transactions appearing as successfully completed within expected timeframes. Neither of the patients involved in this safety event experienced permanent harm. The findings of this investigation were reviewed at our departmental Pathology Morbidity and Mortality conference together with stakeholders from hospital maintenance. Conclusion The root causes for PTDS technical malfunctioning leading to this safety event remain uncertain despite a collaborative RCA. This multidisciplinary retrospective RCA process, however, provided an opportunity for greater awareness of the complex mechanism of the PTDS, promoted awareness of the roles of the various stakeholders involved, and fostered interdepartmental collaboration to prevent future patient safety incidents using quality improvement principles. Table Disclosures No relevant conflicts of interest to declare.

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