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Incident reporting in operation theatre

Tamás Vass, Attila Zaránd, Dániel Horányi, László Harsányi
Diverticulitis of the vermiform appendix is a rare disease with clinical features often similar to conventional acute appendicitis. The importance of appendiceal diverticulosis is the fact that it can lead to an early and a higher incidence of perforation and therefore a higher mortality rate, in contrast to acute appendicitis alone. In this study we present the clinicopathology, diagnosis and therapy of the disease with a review of the literature. A 65-year-old woman presented to the emergency department with a 48-hour history of intermittent pain in the right iliac fossa...
May 2018: Orvosi Hetilap
Berit T Valeberg, Ingrid Liodden, Bergsvein Grimsmo, Lillemor Lindwall
Aim: The aim of the study was to describe how nurse anaesthetist students experienced patient dignity in perioperative practice. Design: A hermeneutical design and the critical incident technique were used to obtain experiences from practice. Method: In the Autumn of 2015, after participating in a mandatory lecture on ethics, 23 nurse anaesthetist students reported their experiences and interpretation concerning violation and preservation of patients' dignity in the operating theatre...
January 2018: Nursing Open
Naomi Potts, Daphne Se Martin, Leontia Hoy
This work is set in the context of perioperative practice in difficult airway management. It integrates a root cause analysis and fish bone technique to investigate a critical incident in temporary yet crucial equipment failure. Risk management and incident reporting is analysed alongside human factors in the operating theatre environment. Finally, recommendations for risk reduction, vigilance and checking vital airway equipment are made in anaesthetic practice.
April 2017: Journal of Perioperative Practice
Uli Schmiddem, N Hawi, E M Suero, R Meller
INTRODUCTION: We report a case of a lost metal platelet from a radiofrequency ablation probe (VAPR VUE Radiofrequency System, Cool Pulse 90, DePuy, Synthes, Switzerland) in the shoulder joint during elective arthroscopic cuff repair. To the best of our knowledge, this kind of an incident during elective arthroscopy has not been described in the literature so far. In addition, we present an algorithm on how to deal with such an incident. CASE REPORT: A 69-year-old woman underwent an arthroscopic subacromial decompression and rotator cuff repair for a torn supraspinatus tendon...
March 2017: Journal of Orthopaedic Case Reports
Hannah Gostlow, Camila Vega Vega, Nicholas Marlow, Wendy Babidge, Guy Maddern
OBJECTIVE: To assess and report on surgeons' ability to identify and manage incidences of harassment. BACKGROUND: The Royal Australasian College of Surgeons is committed to driving out discrimination, bullying, harassment, and sexual harassment from surgical training and practice, through changing the culture of the workplace. To eradicate these behaviors, it is first critical to understand how the current workforce responds to these actions. METHODS: A retrospective analysis of video data of an operating theatre simulation was conducted to identify how surgeons, from a range of experience levels, react to instances of harassment...
July 24, 2017: Annals of Surgery
Rongrong Rueangchira-Urai, Panthila Rujirojindakul, Alan Frederick Geater, Edward McNeil
OBJECTIVE: The aim of this study was to determine the incidence of bacterial and fungal contamination in anaesthetic and vasopressor drugs before and after use in operating theatres. METHODS: A cross-sectional study was conducted in the operating theatres of a university hospital. We collected 945 samples of three different drugs, namely, propofol, vecuronium and ephedrine, from 20 operating rooms and refrigerators where the unused drugs were stored. Each drug was divided into two groups, the pre-use group and the post-use group...
February 2017: Turkish Journal of Anaesthesiology and Reanimation
M Naidoo, J Moodley, P Gathiram, B Sartorius
BACKGROUND: In South Africa (SA), the Saving Mothers Reports have shown an alarming increase in deaths during or after caesarean delivery. OBJECTIVE: To improve maternal surgical safety in KwaZulu-Natal Province, SA, by implementing the modified World Health Organization surgical safety checklist for maternity care (MSSCL) in maternity operating theatres. METHODS: The study was a stratified cluster-randomised controlled trial conducted from March to November 2013...
February 27, 2017: South African Medical Journal, Suid-Afrikaanse Tydskrif Vir Geneeskunde
N A Jagodzinski, S Ibish, D Furniss
We carried out a systematic review to determine the incidence of infection for hand surgery done in settings other than the operating theatre. Databases were searched and a PRISMA chart created by three independent reviewers. From 1200 studies identified, 46 full text articles were reviewed and six were included (two Level 3 studies and four Level 4). In three studies there were no infections after surgery in an office, procedure room or emergency department. Two studies with a combined number of 1962 procedures reviewed carpal tunnel decompressions and reported identical infection rates of 0...
March 2017: Journal of Hand Surgery, European Volume
Raylene Dias, Lipika Baliarsing, Neeraj Kumar Barnwal, Shweta Mogal, Pinakin Gujjar
BACKGROUND AND AIMS: A high incidence of anxiety has been reported in patients in the operation theatre set up. We developed a short visual clip of 206 s duration depicting the procedure of spinal anaesthesia (SAB) and aimed to compare the effect of this video on perioperative anxiety in patients undergoing procedures under SAB. METHODS: A prospective randomised study of 200 patients undergoing surgery under SAB was conducted. Patients were allotted to either the nonvideo group (Group NV - those who were not shown the video) or the video group (Group V - those who were shown the video)...
November 2016: Indian Journal of Anaesthesia
Raylene Dias, Nandini Dave, Swapna Chiluveru, Madhu Garasia
BACKGROUND AND AIMS: Critical incident reporting helps to identify errors and formulate preventive strategies. Many countries have existing national reporting systems. Such a system is yet to be established in India. We aimed to study the incidence of critical events in the paediatric operation theatre (OT) of our institute. METHODS: We conducted a prospective observational study of all children receiving anaesthesia in paediatric OT over a period of 1 year. They were monitored intraoperatively as well as postoperatively, and critical incidents were noted in terms of date and time of incident, location (OT/post-anaesthesia care unit, clinical category, age of patient, degree of patient harm resulting from the incident, description of what happened and duration of surgery...
November 2016: Indian Journal of Anaesthesia
T Renton, W Sabbah
Aims To review never and serious events related to dentistry between 2005-2014 in England.Methods Data from the National Reporting and Learning System (NRLS), with agreed data protection and intelligence governance, was used - snapshot view using the timeframe January 2005 to May 2014. The Strategic Executive Information System (STEIS) database was reported separately for 2012-2013 and 2013-2014. The free text elements from the database were analysed thematically and reclassified according to the nature of the patient safety incident (PSI)...
July 22, 2016: British Dental Journal
Sophie Reed, Rutendo Ganyani, Richard King, Meghana Pandit
BACKGROUND: In February 2010, the UK National Patient Safety Agency set a mandate that the World Health Organisation's Surgical Safety Checklist (SSC) should be completed for every surgical patient within the NHS in a bid to improve surgical safety. However since its introduction, there have been issues with checklist compliance, staff engagement and surgical serious incidents continue. AIMS: This study seeks to explore if an unavoidable pre-recorded audio delivery of the SSC improves compliance and staff engagement with the checklist...
August 2016: International Journal of Surgery
M N Pemberton
Aim To identify the procedures in dental hospitals where a surgical safety checklist is used and in addition, in England, to identify the understanding of hospitals regarding patient safety incidents requiring reporting as Never Events to NHS England.Method A self-completed questionnaire survey asking about the use of checklists was distributed to 16 dental hospitals associated with undergraduate dental schools in the UK and Ireland in the summer of 2015. For hospitals in England (10), additional questions regarding their understanding of incidents to be reported as Never Events were asked...
June 10, 2016: British Dental Journal
M Seng, G K J Sng, X Zhao, I Venkatachalam, S Salmon, D Fisher
This study investigated the incidence and risk to staff groups for sustaining needlestick injuries (NSIs) in the National University Hospital (NUH), Singapore. A retrospective cohort review of incident NSI cases was undertaken to determine the injury rate, causation, and epidemiological profile of such injuries. Analysis of the risk of sustaining recurrent NSI by occupation and location was done using the Cox proportional hazards model. There were 244 NSI cases in 5957 employees in NUH in 2014, giving an incidence rate of 4·1/100 healthcare workers (HCWs) per year...
September 2016: Epidemiology and Infection
Langhit Kurar
INTRODUCTION: Ankle fractures in the osteoporotic patient are challenging injuries to manage, due to a combination of poor soft tissue, peripheral vascular disease and increased bone fragility, often resulting in more complex fracture patterns. I aim to audit current practice and introduce change by producing recommendations to help improve longer-term functional outcomes. PATIENTS AND METHODS: A retrospective 3-week audit was conducted reviewing results of ankle fracture management in 50 patients aged between 50 and 80 years...
March 2016: Annals of Medicine and Surgery
Dedrick Kok-Hong Chan, Kuok-Chung Lee
BACKGROUND: Intestinal tuberculosis can mimic many conditions. The incidence of intestinal tuberculosis in developed countries has risen in tandem with the increase in patients with immunocompromised states. This is a condition which needs to be considered in patients who present with symptoms and signs of bowel perforation on a background of immunosuppression in order to obtain the correct diagnosis and, consequently, the correct treatment. CASE REPORT: We report a patient with a background of sarcoidosis who had been on mycophenolate mofetil, tacrolimus, and high-dose prednisolone...
2015: American Journal of Case Reports
Elizabeth McInnes, Asmara Jammali-Blasi, Sally E M Bell-Syer, Jo C Dumville, Victoria Middleton, Nicky Cullum
BACKGROUND: Pressure ulcers (i.e. bedsores, pressure sores, pressure injuries, decubitus ulcers) are areas of localised damage to the skin and underlying tissue. They are common in the elderly and immobile, and costly in financial and human terms. Pressure-relieving support surfaces (i.e. beds, mattresses, seat cushions etc) are used to help prevent ulcer development. OBJECTIVES: This systematic review seeks to establish:(1) the extent to which pressure-relieving support surfaces reduce the incidence of pressure ulcers compared with standard support surfaces, and,(2) their comparative effectiveness in ulcer prevention...
September 3, 2015: Cochrane Database of Systematic Reviews
Laura Lamprell, Venkat Vangaveti, Derelle Young, John Orton
We thank Gibbs and Commons for their interest in our paper. There is a key difference between the datasets for Commons et al and our study. Our data set, has grouped five years of data according to the calendar year. This is different from Commons et al's study population recruited between 01 June 2009 and 31 May 2010. We feel this may explain the difference of one case between the two papers in 2010. Our data collection used the standard clinic and operating theatre databases, and we were advised that there was no searchable clinical code for grommet procedures undertaken with local anaesthetic (LA) in the outpatient clinic...
June 2015: Diving and Hyperbaric Medicine: the Journal of the South Pacific Underwater Medicine Society
J S Rutherford, R Flin, A Irwin
The outcome of critical incidents in the operating theatre has been shown to be influenced by the behaviour of anaesthetic technicians (ATs) assisting anaesthetists, but the specific non-technical skills involved have not been described. We performed a review of critical incidents (n=1433) reported to the Australian Incident Monitoring System between 2002 and 2008 to identify which non-technical skills were used by ATs. The reports were assessed if they mentioned anaesthetic assistance or had the boxes ticked to identify "inadequate assistance" or "absent supervision or assistance"...
July 2015: Anaesthesia and Intensive Care
Basil Enicker, Sonwabile Gonya, Timothy C Hardcastle
BACKGROUND: Spinal stab wounds presenting with retained knife blades (RKB) are uncommon, often resulting in spinal cord injury (SCI) with catastrophic neurological consequences. The purpose of this study is to report a single unit's experience in management of this pattern of injury at this regional referral centre. METHODS: Retrospective review of medical records identified 51 consecutive patients with spinal stabs presenting with a RKB at the Neurosurgery Department at Inkosi Albert Luthuli Central Hospital between January 2003 and February 2015...
September 2015: Injury
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