Fire in operating room: The adverse “never” event. Case report, mini-review and medico-legal considerations

Spagnolo, Elvira Ventura; Mondello, Cristina; Roccuzzo, Salvatore; Baldino, Gennaro; Sapienza, Daniela; Gualniera, Patrizia; Asmundo, Alessio

doi:10.1016/j.legalmed.2021.101879

Cited by 3 publications

(3 citation statements)

References 37 publications

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“…We excluded another 337 articles after reviewing the full-text citations largely because they neither identified individual NEs nor specified an existing framework (47%), or because they were non-scholarly (eg, media releases; 30%). Thus, our analyses were based on 367 articles 3 4 7–11 18–377. A full list of these articles and the information we extracted from them are found in online supplemental tables 1 and 2.…”

Section: Resultsmentioning

confidence: 99%

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

et al. 2023

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BackgroundNever events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?MethodsFor this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework.ResultsOur analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as ‘wholly preventable’. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy).ConclusionsTo improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.

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Section: Resultsmentioning

confidence: 99%

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

et al. 2023

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“…6 Authors of a case report of a patient who underwent a total thyroidectomy described a situation in which a fire occurred when the perioperative team intraoperatively reapplied 2% chlorhexidine gluconate and 70% isopropyl alcohol immediately before wound closure. 12 The patient was draped and the team members did not allow the solutions to dry before the surgeon used the monopolar electrosurgical unit, which ignited the solution and spread to the surgical drapes. The operative team members promptly extinguished the fire; however, the patient experienced second-and third-degree burns to the anterolateral surface of the neck.…”

Section: Fire Safetymentioning

confidence: 99%

Guidelines in Practice: A Safe Environment of Care

Kneisley

2024

AORN Journal

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Creating a safe environment for performing surgical procedures is essential to achieve successful patient outcomes and protect the perioperative personnel who are providing care. Numerous factors challenge the provision of a safe environment of care and create a complex setting for perioperative nurses to manage. The updated AORN “Guideline for a safe environment of care” provides perioperative nurses with recommendations for establishing a safe environment for both patients and personnel. This article provides an overview of the guideline and discusses recommendations for implementing fire safety protocols, using warming cabinets, and creating a latex‐safe environment. It also includes a scenario describing the care of a patient with an unidentified latex allergy who is undergoing a laparoscopic sleeve gastrectomy and hiatal hernia repair. Perioperative nurses should review the guideline in its entirety and implement recommendations as applicable in operative and other procedural settings.

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“…According to the most recent data in the scientific literature, it is possible to consider thyroidectomy as a low-risk surgery ( 10 ), even in patients commonly considered to be at higher surgical risk. The most common complications that are annually recorded in the post-operative phase are hypocalcemia and recurrent laryngeal nerve injury, as well as hematomas of the neck region and skin scarring abnormalities; while the vascular and other complications such as nerve plexus injuries are much less represented ( 11 , 12 ). Unfortunately, in the literature are reported rarer but more serious adverse events, such as bilateral recurrent nerve paralysis which result in fixation of the vocal cords and the esophagus lesion ( 13 ).…”

Section: Introductionmentioning

confidence: 99%

Professional liability due to complete esophagus section during thyroidectomy: a rare case report

Mondello¹,

Baldino²,

Cianci³

et al. 2023

Gland Surg

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Background: Several diagnostic and therapeutic processes are regulated by guidelines and recommendations provided by International and National Societies which offer standardized indications for health-care practitioners, including the treatment of pathologies that may affect the thyroid gland.These documents are very important for patient health promotion and, also, for preventing adverse events associated with patient injuries and related malpractice litigations. Particularly, thyroid surgery can be a cause of professional liability due to complications from surgical errors. Even if the most frequent complications are hypocalcemia and recurrent laryngeal nerve injury, this surgical specialty can be also burdened by other rare and serious adverse events such as esophagus lesions.Case Description: Here a case of alleged medical malpractice involving a 22-year-old woman reporting a complete esophagus section during thyroidectomy was described. The case analysis highlighted that the surgical treatment was performed for an unconfirmed Graves-Basedow disease which was then assessed as Hashimoto thyroiditis by histological exam of the removed gland. The esophagus section was treated by termino-terminal pharyngo-jejunal anastomosis and termino-terminal jejuno-esophagus anastomosis. The medico-legal analysis of the case revealed two different profiles of medical malpractice related, respectively, to the misdiagnosis of the pathology due to an inappropriate diagnostic-therapeutic procedure and the production of the complete section of the esophagus, representing an extremely rare complication of thyroidectomy.Conclusions: Clinicians should ensure an adequate diagnostic-therapeutic path based on guidelines, operational procedures, and evidence-based publications. The non-observance of the "required rules" for diagnosis and treatment of thyroid disease can be associated with a very rare and severe complication that strongly compromises the patient quality of life.

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Fire in operating room: The adverse “never” event. Case report, mini-review and medico-legal considerations

Cited by 3 publications

References 37 publications

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

Guidelines in Practice: A Safe Environment of Care

Professional liability due to complete esophagus section during thyroidectomy: a rare case report

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