Background: It is an important study to investigate incident reports submitted by multidisciplinaries in the Special Functioning Hospitals of Japan. We clarify the characteristics of the incidents and evaluate the outcomes obtained from a polygonal analysis. Material and Methods: We collected 1638 incident reports submitted by multidisciplinaries for one year from April, 2016 to March, 2017. The incidents were retrospectively analyzed by profile, levels, distribution, and ratios. Results: The majority of incidents (94.7%, 1551/1638) were distributed between the levels 0 to 3a, on the other hand, the incidents of a level higher than 3b occupied 5.3%. The reports from nurses were 75.3% (1234/1638) and those from doctors were 12.8% (209/1638). The level 3b totalled 30.6% (64/209) of the doctor-reported incidents. In contrast, the level 2 totalled 33.8% (417/1234) of the nurse-reported incidents. The levels of the doctor-incidents were comparatively higher than those of the nurse-incidents. The profiles of the incidents were categorized as drug administration (n = 439, 26.8%), nursing care (n = 399, 24.4%), drain and tube (n = 258, 15.8%), medical treatment and care (n = 199, 12.1%), medical examination (n = 141, 8.6%), medical equipment (n = 99, 6.0%), giving instructions (n = 66, 4.0%) and blood transfusion (n = 12, 0.7%). Conclusions: It is important for multidisciplinaries to report incidents because they can learn novel experiences from the incidents for preventing a recurrence. By proper utilizing of the incident-reporting system, it could be an effective tool that helps the medical staff build a strong patient safety culture,
Background: We investigated the changes in consciousness of operating team staffs and the influences on the operating time after the implementation of the surgical safety checklist (SSC) using a questionnaire survey. Materials and Methods: 206 operating team staffs (148 surgeons, 20 anesthesiologists, 38 nurses) replied to the questionnaire survey, and the changes in consciousness were checked before and after the implementation of the SSC. We retrospectively investigated the operating time from medical and anesthesia records at the point 2 months before (pre-implementation (pre-I): n = 656) and 2 months after (post-implementation (post-I): n = 650) the implementation. We compared the scheduled operating time, the actual operating time, and the ratio between the two groups. Results: We received replies from 156 operating team staffs, i.e., the recovery rate was 75.7% (156/206). The operating team staffs were interested in 9 items, which included the self-introduction of members, patient referral, surgical procedure, scheduled operating time, predicted blood loss, important matters in the operation, timing of antibiotics, and important matters in anesthesia, and preparation of required materials and equipment. In the multidisciplinary teamwork, they had increased the consciousness of responsibility and communication. There was no significant difference in the scheduled operating time (post-I: 186.9 ± 131.9; pre-I: 184.8 ± 127.8 minutes) and the actual operating time (post-I: 170.8 ± 148.1 How to cite this paper: Ayabe, T., Shinpuku, G., Tomita, M., Nakamura, S., Yokoyama, E., Shimizu, S., Okumura, M., Itai, K., Tsuneyoshi, I., Takeshima, H. and Nakamura, K. (2017) 23minutes; the pre-I: 174.6 ± 147.3 minutes). However, regarding the ratio of the actual operating time to the scheduled operating time, there was a significant difference (the post-I: 0.90 ± 0.43; the pre-I: 0.95 ± 0.45). Use of the SSC significantly decreased the actual operating time. Conclusion: The outcomes of the implementation of SSC resulted in changes in the safety consciousness of the operating team staffs such as their increased responsibility and communication. The improved multidisciplinary teamwork might make them realize a smooth operating progression to shorten the actual operating time.
Background: We experienced a very rare complication, that is, an unexpected postoperative paraplegia due to the incidental migration of oxidized regenerated cellulose used for hemostasis of intercostal space bleeding. Patients and Methods: The objective is to analyze the cause and to take measures against the very rare complication from an empirical analysis and the literature. For a 78-year-old male with suspected lung cancer in the right upper lobe (S 1 ), a thoracotomy was performed. For hemostasis of the bleeding from the 5 th intercostal thoracotomy space, we used and placed oxidized regenerated cellulose at the continuous oozing bleeding sites. On the 3 rd postoperative day, paralysis beneath thoracic vertebrae level 6 was observed. Immediate computed-tomographic (CT) scanning and magnetic resonance imaging (MRI) displayed a 17 × 9 × 14 mm epidural hematoma in the spinal canal at level 5 of the thoracic vertebrae. An emergent laminectomy for the thoracic vertebra was performed to remove the oxidative cellulose and haematoma, and the compression was released. The paraplegia gradually began to recover and maintain a standing position. After 1 year from the event, the patient can walk by himself with a crutch. Results: The causes were that the oxidative cellulose materials were used for the intercostal bleeding at the open thoracotomy. The migration of the oxidative cellulose materials into the epidural space and into thoracic spinal canal through the intervertebral foramen, or gradual penetraHow to cite this paper: Ayabe, T., Tomita, M., Shimizu, S., Yokoyama, E., Okumura, M., Itai, K. and Nakamura, K. tion of the oxidative cellulose materials into the spinal canal due to respiratory costal movement. As a measurement of prevention, the hemostat materials should be completely removed after finishing of the hemostasis. In the case of a difficult hemostasis, consultation of an orthopedist or neurosurgeon to perform the appropriate hemostasis in good cooperation is required. Conclusion: If postoperative paraplegia is suspected, immediate CT scanning and/or MRI examination would become powerful diagnostic procedures as soon as possible to start an interventional treatment.
Background: The implementation of resilience engineering for an operating room is difficult; however, its study would become important for the surgeon's personal and surgical team in order to develop a new surgical safety management. An expert operator must perform an operation with his surgical team that includes an anesthetist, scrub nurse, and young assistant. However, there exist some gaps among these multi-professionals. Objective: From the viewpoint of an expert operator, to have an operation go well, we would describe how to reconcile their gaps. We will explain the gaps among the multi-professionals in a surgical team, such as hidden interactions between the operator and anesthetist, surgeon and scrub nurse, and expert operator and young assistant. Material and Methods: We assumed three types of interactions among the multi-professionals in the operating theater and we clarified how to bridge the gaps by revealing what the operator thinks, what the anesthetist thinks, what the scrub nurse thinks, and what the young assistant thinks in the surgical team, and by understanding how they perform during surgery. Outcomes: What the expert operator thinks and how he performs in surgery is summarized by the following three items: 1) safety is first, 2) achieving the operative purpose, and 3) fast surgery. We interviewed the surgical team members. In order for the surgery to go well, what the important thing is "safety first" for any surgical professionals. The sentence, "safety is first" is the magic words, such as "open sesame".
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