What do we Know about Contributing Factors for “Never Events” in Operating Rooms? A Machine Learning Analysis

BackgroundA Surgical “Never Event” (NE) is a preventable error. Various factors contribute to the occurrence of wrong site surgery and retained foreign item, but little is known about their quantified risk in relation to surgery's characteristics. Our study uses machine learning to reveal factors and quantify their risk to improve patient safety and quality of care.MethodsWe used data from 9,234 observations on safety standards and 101 Root-Cause Analysis from actual NEs, and utilized three Random Forest supervised machine learning models. Using a standard 10-cross validation technique, we evaluated the model's metrics, and, through Gini impurity we measured the impact of factors thereof to occurrence of the two types of NEs. ResultsWe identified 24 contributing factors in six surgical departments. Two had an impact of >900% in Urology, Orthopedics and General Surgery, six had an impact of 0–900% in Gynecology, Urology and Cardiology, and 17 had an impact of <0%. Factors' combination revealed 15-20 pairs with an increased probability in five departments: Gynecology:875–1900%; Urology: 1,900:2,600%; Cardiology:833–1,500%; Orthopedics:1,825–4,225%; and General Surgery:2,720–13,600%. Five factors affected the occurrence of wrong site surgery (-60.96–503.92%) and five of retained foreign body (-74.65–151.43%), three of them overlapping: two nurses (66.26–87.92%), Surgery length<1 hour (85.56–122.91%), Surgery length 1-2 hours (-60.96–85.56%).ConclusionsThe use of machine learning has enabled us to quantify the potential impact of risk factors for wrong site surgeries and retained foreign items, in relation to surgery's characteristics, which in turn suggests tailoring the safety standards accordingly. Trial registration number: MOH 032-2019

EP.TH.25Common General Surgical Never Events: An In-depth Analysis of Never Events data held by NHS England

Background There is little available data on common general surgical NE. Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. The purpose of this study was to identify common general surgical NE from the data held by the National Health Service (NHS) England. Methods We analyzed NHS England NE data from April 2012 to February 2020 to identify common general surgical NE. Results There was a total of 797 general surgical NE identified under three main categories of Wrong-Site Surgery (n = 427;53.58%), Retained Items Post-Procedure (n = 355;44.54%) and Wrong Implant/Prosthesis and (n = 15;1.88%). We identified a total of 56 common general surgical themes - 25 each in Wrong-Site Surgery and Retained Foreign Body category and 6 in wrong implants. Wrong skin condition surgery was the commonest wrong-site surgery (n = 117;27.4%). There were 18 wrong side chest drains (4.2%) and 18 (4.2%) wrong side angioplasty/angiogram. There were 7 (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and 6 (1.4%) instances of biopsy of cervix rather than colon or rectum. Retained surgical swabs were the most common retained items (n = 165;46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guidewires, 26 (7.3%) surgical needles; and 9 (2.5%) surgical drains. Wrong stents were the most common (n = 9;60%) wrong implant followed by wrong breast implants (n = 2;13.3%). Conclusion This study found 56 common general surgical Never Events. Increased awareness of these common themes of NE may ultimately help reduce their incidence.

SP7.1.5 Common General Surgical Never Events: Analysis of NHS England Never Events Data

Background There is little available data on common general surgical Never Events (NE). Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. The purpose of this study was to identify common general surgical NE from the data held by the NHS England. Methods We analysed NHS England NE data from April 2012 to February 2020 to identify common general surgical NE. Results There was a total of 797 general surgical NE identified under three main categories of Wrong-Site Surgery (n = 427;53.58%), Retained Items Post-Procedure (n = 355; 44.54%), and Wrong Implant/ Prosthesis and (n = 15; 1.88%). We identified a total of 56 common general surgical themes - 25 each in the Wrong-Site Surgery and Retained Foreign Body category and 6 in wrong implants. Wrong skin condition surgery was the commonest wrong-site surgery (n = 117; 27.4%). There were 18 wrong side chest drains (4.2%) and 18 (4.2%) wrong side angioplasty/angiogram. There were 7 (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and 6 (1.4%) instances of biopsy of cervix rather than colon or rectum. Retained surgical swabs were the most common retained items (n = 165;46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guidewires, 26 (7.3%) surgical needles; and 9 (2.5%) surgical drains. Wrong stents were most common (n = 9;60%) wrong implant followed by wrong breast implants (n = 2;13.3%). Conclusion This study found 56 common general surgical NE. Increased awareness of these common themes of NE may help reduce their incidence.

Analysis and outcomes of wrong site thyroid surgery

Background In thyroid surgery, wrong-site surgery (WSS) is considered a rare event and seldom reported in the literature. Case presentation This report presents 5 WSS cases following thyroid surgery in a 20-year period. We stratified the subtypes of WSS in wrong target, wrong side, wrong procedure and wrong patient. Only planned and elective thyroid surgeries present WSS cases. The interventions were performed in low-volume hospitals, and subsequently, the patients were referred to our centres. Four cases of wrong-target procedures (thymectomies [n = 3] and lymph node excision [n = 1] performed instead of thyroidectomies) and one case of wrong-side procedure were observed in this study. Two wrong target cases resulting additionally in wrong procedure were noted. Wrong patient cases were not detected in the review. Patients experienced benign, malignant, or suspicious pathology and underwent traditional surgery (no endoscopic or robotic surgery). 40% of WSS led to legal action against the surgeon or a monetary settlement. Conclusion WSS is also observed in thyroid surgery. Considering that reports regarding the serious complications of WSS are not yet available, these complications should be discussed with the surgical community. Etiologic causes, outcomes, preventive strategies of WSS and expert opinion are presented.

Nachexzision eines Basalzellkarzinoms an der falschen Lokalisation

ZusammenfassungEine Patientin stellte sich in der Sprechstunde einer dermatologischen Klinik wegen zweier Hautveränderungen im Bereich der Nase vor. Der behandelnde Dermatologe entfernte diese in Form tangentialer Abtragungen; die histologische Untersuchung ergab das Vorliegen eines Angiofibroms sowie eines Basalzellkarzinoms, welches nicht im Gesunden entfernt worden war. In Absprache mit der Patientin erfolgte eine Nachexzision. Diese wurde von einem zweiten Dermatologen der Klinik auf der Basis einer unklaren Dokumentation der Primärexzision an einer falschen Stelle durchgeführt.Die Patientin bemängelte die operative Behandlung; deshalb sei eine weitere Operation an der Nase erforderlich geworden. Die Schlichtungsstelle bestätigte, dass es fehlerbedingt zu einer nicht notwendigen Exzision an falscher Stelle mit entsprechender Narbenbildung sowie zu einem ohne den Fehler nicht erforderlichen weiteren Eingriff gekommen sei.Der an der falschen Lokalisation durchgeführte dermatochirurgische Eingriff („wrong site surgery“) ist ein in der Dermatochirurgie bekanntes Fehlergeschehen. Als Präventionsmaßnahme hat sich eine sog. „Time-out“ („Auszeit“) bewährt, wobei vor und ggf. während einer Operation diese unterbrochen wird zur Bestätigung des richtigen Patienten, Eingriffs und Ortes. Im vorliegenden Fall wurde die Wahl des falschen Nachexzisionsortes gefördert durch eine unklare Dokumentation der Primärexzision und eine fehlende Kommunikation zwischen den behandelnden Dermatologen über die korrekte Exzisionsstelle. Gemäß § 630 h BGB tritt eine Beweislastumkehr bei der Haftung für Behandlungs- und Aufklärungsfehler ein, wenn es sich um ein sog. „voll beherrschbares Risiko“ handelt; um ein solches handelt es sich bei einer Exzisionsstellenverwechslung. Der berichtete Fall beleuchtet gleichzeitig die Probleme der ärztlichen Arbeitsteilung; nach der sog. „horizontalen Arbeitsteilung“ darf jeder Facharzt zunächst darauf vertrauen, dass ein anderer an der Behandlung beteiligter Facharzt seine Pflichten aus dem Behandlungsvertrag korrekt erfüllt. Entstehen jedoch Zweifel, wie im vorliegenden Fall bzgl. der Dokumentation der korrekten Exzisionsstelle, darf der zweitbehandelnde Arzt nicht unbesehen handeln, sondern muss sich selbstverantwortlich der richtigen Diagnose, in diesem Fall bzgl. der Lokalisation des Basalzellkarzinoms, vergewissern. Durch eine Nachfrage beim erstbehandelnden Dermatologen wäre der Behandlungsfehler zu vermeiden gewesen.