Surgical errors

Although the endoscopes provide bright illumination and brilliant images, the view provided is only a two-dimensional representation of a complex three-dimensional space. Endoscopes provide a wide-angle perspective, which intrinsically introduce a fish-eye effect (analogous to spherical aberration) and the potential for perceptual distortion and secondary surgical error during these procedures is... 

Quality The image quality has to be comparable with the one of the direct visualization. Low image quality can lead to surgical errors or surgeon discomfort. 

Table 1. Examples of OR surgical error chains as applied to dialysis access surgery... 

Medication errors are costly to both the patient (direct costs such as additional treatment and increased hospital stay) and to society (indirect costs such as decreased employment, costs of litigation) [1,5]. The cost of medication errors in a 700-bed teaching hospital based on a study in eleven medical and surgical units in two hospitals over a six-month period, was estimated to be 2.8 million dollars annually [2]. The increased length of stay associated with a medication error was estimated to be 4.6 days [2]. In a four-year study of the eosts of adverse drug events (ADEs) in a tertiary care center, 1% of these events were elassified as medication errors. The excess hospital costs for ADEs over the study period were almost 4,500,000 with almost 4,000 days of increased hospital stay [12]. 

Improper administration of antimicrobial prophylaxis leads to excessive surgical wound infection rates. Common errors in antibiotic prophylaxis include selection of the wrong antibiotic, administering the first dose too early or too late, failure to repeat doses during prolonged procedures, excessive duration of prophylaxis, and inappropriate use of broad-spectrum antibiotics. 

Safety and risk considerations are often at the center of mistake proofing. Imagine the risk associated with unveiling new investment software, or with implementing a new surgical procedure. Both the financial and health care industries have a host of mistake-proofing measures in place to avoid costly errors and litigation. 

The patient test results are the final product of most laboratory procedures, and the monitoring of these results is the most direct form of QC. Unfortunately, procedures for monitoring results are not very sensitive and have low probabilities for error detection. The most effective procedure is the chnical correlation of test results with other information related to the patient, especially surgical findings, response to therapy, and autopsy data. Less sensitive but easier to implement are comparisons with previous test values and correlation with related test results. The easiest procedure is the comparison of test results with physiological or probabilistic limits. 

Surgery to correct refractive errors for the improvement of visual acuity generally aims at changing the corneal curvature. Corneal tissue is mainly constituted of a network of natural collagen polymer with the void volume filled with a special type of aqueous saline solution. A wide variety of laser and nonlaser procedures, such as laser-assisted in situ keratomileusis (LA-SIK), laser-cut channels for intracorneal ring segment (ICRS) implantation, femtosecond lamellar keratoplasty (FLK), intrastromal vision correction, and corneal transplantation have been developed for refractive surgical correction [83, 84]. They include removal of corneal tissue from the surface, removal of corneal tissue from the interior or stroma, and alteration of the corneal mechanical properties to produce a refractive effect. The most popular by far are procedures based on excimer laser ablation of the corneal surface and/or stroma [85]. 

The presence of benign ectopic epithelial structures in lymph nodes and soft tissue parts can be an error source while screening of lymph nodes and surgical margins for micrometastases. These epithelial structures can be of different origin such as Mullerian epithelial inclusions and endometriosis in pelvic and abdominal lymph nodes or heterotopic ducts and glands in abdominal, thoracic and cervical lymph nodes. Microscopic examination of H E tissue sections prior to molecular examination can be helpful to exclude the presence of such epithelial structures. 

USA) 1995. Phase 1 14 days phase 2 5 days paediatric teaching hospital. Phase 1 2 units (ICU and medical surgical unit). Phase 2 3 units (ICU, medical and surgical units) Following medication order written from prescribing through administration. Also review of medical record, pharmacy s clinical interventions and quality control log, and incident reports. Also review of medication administration record Sample 3312 medication orders Error rate 24/100 orders Administration error 0.15% doses administered... 

Nixon and Dhillon, 1996 (UK) 2 weeks General hospital -two paediatric wards (one medical and one surgical) 487 and 425 administration observed for medical and surgical wards respectively. No. of patients not mentioned Observation from Sam to 8pm, Monday to Saturday Administration errors 5.6% and 4.5% for respective wards... 

Herout P M, Erstad B L (2004). Medication errors involving continuously infused medications in a surgical intensive care unit. Crit Care Med 32 428-432. 

Although Codman was ostracized and ridiculed by many, his proposals were nevertheless adopted by the American Surgical Society, but the eventual minimum standards for hospitals instituted after the First World War omitted two of the most crucial components the analysis of outcomes and the classification of error. The Minimum Standard ran until 1952, until it was overtaken by the formation of the organization that eventually became the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the largest accrediting body in the United States (Sharpe and Faden, 1998). 

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