Characterising ‘near miss’ events in complex laparoscopic surgery through video analysis

Abstract

BackgroundRoot cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical errors is essential for developing rescue mechanisms to prevent adverse outcomes.ObjectiveDescriptive study to characterise intraoperative technical error-event patterns in successful laparoscopic procedures.MethodsEvents (injuries) identified during prior blinded analyses of 54 unedited recordings of bariatric laparoscopic procedures were subjected to a secondary review to determine the presumed underlying error mechanism. The recordings were obtained from one university-based bariatric collaborative programme, and represented consultant, fellow and shared trainee cases.ResultsSixty-six events were identified in 38 recordings, while 16 videos showed no events. In 25 (66%) of the videos that showed events, additional measures such as haemostasis or suture repair were required. Common identified events were minor bleeding (n=39, 59%), thermal injury to non-target tissue (n=7, 11%), serosal tears (n=6, 9%). Common error mechanisms were ‘inadequate use of force/distance (too much)’ (n=20, 30%) and ‘inadequate visualisation’ during grasping/dissecting (n=6, 9%), ‘inadequate use of force/distance (too much)’ using an energy device (n=6, 9%), or during suturing (n=6, 9%). All events were recognised intraoperatively.ConclusionsAnalysis of successful operations allowed the identification of numerous error-event sequences. Reviewing injury mechanisms can enhance surgeons’ understanding of relevant errors. This error awareness may aid surgeons in preparing for cases, help avoid errors and mitigate their consequences. Thus, this approach may impact future surgical education and quality initiatives aimed at reducing surgical risks.

Patients and hospital managers want laparoscopic simulation training to become mandatory before live operating: a multicentre qualitative study of stakeholder perceptions

“…Current initiatives to improve patient safety in surgery with an emphasis on system approaches, such as optimal antibiotic or heparin use, have had a minimal impact on surgical outcomes 2. However, it has been shown that peer video ratings of surgical skill strongly correlated with improved patient outcomes 3. Consequently, there has been growing interest in focusing on the operation itself.…”

Historie van het onderwijs in de urologie

“…Het is een uitdaging om een simpel, kosteneffectief en valide meetinstrument te ontwikkelen, dat tegemoet zal komen aan deze eisen van de overheid, patiëntengroepen, maar ook aan de eisen van professionals zelf. In de toekomst zou videoanalyse daarin mogelijk nog een belangrijke rol kunnen gaan spelen [10]. De ultieme doelstelling blijft: de kwaliteit van het medisch specialistisch handelen steeds verder optimaliseren en de patiëntveiligheid verbeteren.…”

Surgical video analysis: an emerging tool for improving surgeon performance

“…Bonrath et al 4 add to our scientific understanding of intraoperative surgeon performance. The investigators reviewed 54 unedited videos of successful (uncomplicated) laparoscopic bariatric procedures to identify near-miss events using the Generic Error Rating Tool (GERT).…”