Laparoscopic cholecystectomy: device-related errors revealed through a national database

Abstract

Laparoscopic techniques represent a key milestone in the development of modern surgery, offering a step change in quality of care, patient satisfaction and efficiency in use of health service resources. Laparoscopy is most widely used for gall bladder surgery. As would be expected with the introduction of any new technology, the early phase of development was accompanied by complications in its use. Arguably some of these should have been anticipated, but nevertheless standards and training programs were subsequently put in place to secure a more consistent standard of care across the UK. Now that this early learning curve has largely been negotiated, we wanted to examine the nature of the errors associated with laparoscopic gall bladder surgery, particularly in relation to equipment. We used data from the largest error-reporting system in the world to examine the problem of equipment-related incidents amongst patients who had laparoscopic cholecystectomy. Over the 6-year period 2004-2010, the number of such reports increased 15-fold, whilst the growth in use of the procedure itself increased 1.3-fold. The majority of the increase was in device-related errors. User-related errors constituted a smaller proportion of errors. Whilst most surgeons appear to carry out laparoscopic surgery with a low level of harm to their patients, problems with their equipment remains a risk for many procedures. In some ways, this is an easier problem to address than one associated with competency. A risk associated with faulty, substandard or misused equipment is one that should be minimized in a 21st Century surgical service.

Errors in the management of cardiac arrests: An observational study of patient safety incidents in England

“…The detailed structure of the database has been described elsewhere. 9 The national database of patient safety incidents now contains around nine million reports. For most of its existence, this database, the National Reporting and Learning System (NRLS), was managed by an independent agency within the NHS called the National Patient Safety Agency (NPSA).…”

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice

“…Leading experts recognise that despite limitations of reporting systems (under-reporting, incomplete view of incident and reporting biases), they provide multiple perspectives over time and form an integral part of routine monitoring in clinical practice. 29 The NRLS has provided insight into understanding underlying system failures and has helped identify areas for intervention in secondary care, including: (1) prescribing and monitoring lithium therapy; 30 (2) reliable administration of insulin; 31 (3) early detection of complications in surgical care; [32][33][34] and (4) essential care after an inpatient fall. 35 Furthermore, clinical researchers have explored descriptions of patient safety incidents in anaesthesia and identified system deficiencies relating to practical procedures, communication of information to patients, verbal and written communication practices, and continuity of care.…”

Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids

“…None of the reports included any evidence of actual patient harm. There was no clear pattern of incident reporting over time; the absence of reports pre-2005 is likely to reflect the fact that the NRLS was still in development and not yet fully established as a national presence 20 28…”

“…Data are anonymised to remove details that identify any patients or staff. A full description of the NRLS database can be found elsewhere 20 27…”