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01-06-2021 | Bariatric Surgery | Original Contributions

Analysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgery

Authors: Islam Omar, Brijesh Madhok, Chetan Parmar, Omar Khan, Michael Wilson, Kamal Mahawar

Published in: Obesity Surgery | Issue 6/2021

Abstract

Background

Hundreds of thousands of patient-safety clinical incidents are reported to the National Reporting and Learning System (NRLS) database in England and Wales every year. The purpose of this study was to identify bariatric surgery-related learning points from these incidents.

Methods

We analysed bariatric surgery-related clinical incidents reported to the NRLS database between 01 April 2005 and 31st October 2020. The authors used their experience to identify learning themes, attribute severity, and design a safety checklist from these reported incidents.

Results

We identified 541 bariatric surgery-related clinical incidents in 58 different themes. Preoperative, intraoperative, and postoperative incidents represented 30.3% (N = 164), 38.1% (N = 206), and 31.6% (N = 171) incidents respectively. One hundred fifty (27.7%), 244 (45.1%), and 147 (27.2%) incidents were attributed high, medium, and low severity respectively.

The most commonly reported high severity theme was the failure of thromboprophylaxis (50; 9.2%). Intraoperative high severity incidents included 17 incidents of stapling of orogastric/nasogastric tubes or temperature probes, 8 missed needles, 8 broken graspers, and 6 incidents of band parts left behind. Postoperatively, the most commonly reported high severity theme was improper management of diabetes mellitus (DM) (35; 6.5%). Medication errors represented a significant proportion of the medium severity incidents.

Conclusion

We identified 58 specific themes of bariatric surgery-related clinical incidents. We propose specific recommendations for the prevention of each theme and a safety checklist to help improve the safety of bariatric surgery worldwide.

Peter Small, Kamal Mahawar, Peter Walton, Robin Kinsman. The UK National Bariatric Surgery Registry. Third Registry Report 2020. https://www.bomss.org.uk/wp-content/uploads/2020/10/NBSR-Third-Report-for-website.pdf Last accessed on 11th December 2020.

Almino Ramos, Lilian Kow, Wendy Brown, Richard Welbourn, John Dixon, Robin Kinsman, Peter Walton. The International Federation for the Surgery of Obesity and Metabolic Disorders. Fifth IFSO Global Registry Report 2019. https://www.ifso.com/pdf/5th-ifso-global-registry-report-september-2019.pdf Last accessed on 11th December 2020.

Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–20; discussion 420-2. https://doi.org/10.1097/SLA.0b013e31822c9dac.CrossRefPubMedPubMedCentral

Smith MD, Patterson E, Wahed AS, et al. Thirty-day mortality after bariatric surgery: independently adjudicated causes of death in the longitudinal assessment of bariatric surgery. Obes Surg. 2011;21(11):1687–92. https://doi.org/10.1007/s11695-011-0497-8.CrossRefPubMedPubMedCentral

Dallal RM, Pang J, Soriano I, et al. Bariatric-related medical malpractice experience: survey results amongst ASMBS members. Surg Obes Relat Dis. 2014;10(1):121–4. https://doi.org/10.1016/j.soard.2013.04.015.CrossRefPubMed

Jena AB, Seabury S, Lakdawalla D, et al. Malpractice risk according to physician specialty. N Engl JMed. 2011;365(7):629–36.CrossRef

Kassir R, Lointier P, Papastathi-Boureau C, et al. Medicolegal analysis of 81 malpractice claims against bariatric surgeons in France. Obes Surg. 2020;30(5):1726–35. https://doi.org/10.1007/s11695-020-04389-4.CrossRefPubMed

National Reporting and Learning System. https://report.nrls.nhs.uk/nrlsreporting/ Last Accessed on 8th December 2020.

Choudhry AJ, Haddad NN, Martin M, et al. Medical malpractice in bariatric surgery: a review of 140 medicolegal claims. J Gastrointest Surg. 2017;21(1):146–54. https://doi.org/10.1007/s11605-016-3273-1. Epub 2016 Oct 11CrossRefPubMed

10.

Bruguera M, Delgado S, Viger M, et al. Análisis médico-legal de las reclamaciones judiciales en cirugía bariátrica [Medicolegal analysis of legal claims in bariatric surgery]. Cir Esp. 2012;90(4):254–9. Spanish. https://doi.org/10.1016/j.ciresp.2011.12.003.CrossRefPubMed

11.

Tuchtan L, Kassir R, Sastre B, et al. Medico-legal analysis of legal complaints in bariatric surgery: a 15-year retrospective study. Surg Obes Relat Dis. 2016;12(4):903–9. https://doi.org/10.1016/j.soard.2015.10.067.CrossRefPubMed

12.

Poelemeijer YQM. Marang-van de Mheen PJ, Wouters MWJM, Nienhuijs SW, Liem RSL. Textbook outcome: an ordered composite measure for quality of bariatric surgery. Obes Surg. 2019;29(4):1287–94. https://doi.org/10.1007/s11695-018-03642-1.CrossRefPubMed

13.

Gero D, Raptis DA, Vleeschouwers W, et al. Defining global benchmarks in bariatric surgery: a retrospective multicenter analysis of minimally invasive Roux-en-Y gastric bypass and sleeve gastrectomy. Ann Surg. 2019;270(5):859–67. https://doi.org/10.1097/SLA.0000000000003512.CrossRefPubMed

14.

Giudicelli G, Diana M, Chevallay M, et al. Global benchmark values for laparoscopic Roux-en-Y-gastric bypass: a potential new indicator of the surgical learning curve. Obes Surg. 2020; https://doi.org/10.1007/s11695-020-05030-0.

15.

Kassir R, Debs T, Blanc P, et al. Complications of bariatric surgery: presentation and emergency management. Int J Surg. 2016;27:77–81. https://doi.org/10.1016/j.ijsu.2016.01.067.CrossRefPubMed

16.

Jamal MH, Corcelles R, Shimizu H, et al. Thromboembolic events in bariatric surgery: a large multi-institutional referral center experience. Surg Endosc. 2015;29(2):376–80. https://doi.org/10.1007/s00464-014-3678-4.CrossRefPubMed

17.

Never Events Data. NHS Improvement. https://improvement.nhs.uk/resources/never-events-data / Last accessed on 8th December 2020.

18.

Omar I, Graham Y, Singhal R, et al. Identification of common themes from never events data published by NHS England. World J Surg. 2021;45(3):697–704. https://doi.org/10.1007/s00268-020-05867-7.CrossRefPubMed

19.

Graham YNH, Earl-Sinha C, Parkin L, et al. Evaluating a potential role for community pharmacists in post-bariatric patient nutritional support. Clin Obes. 2020;10(4):e12364. https://doi.org/10.1111/cob.12364.CrossRefPubMed

20.

Rutberg H, Borgstedt-Risberg M, Gustafson P, et al. Adverse events in orthopedic care identified via the Global Trigger Tool in Sweden - implications on preventable prolonged hospitalisations. Patient Saf Surg. 2016;10:23. https://doi.org/10.1186/s13037-016-0112-y.CrossRefPubMedPubMedCentral

Title: Analysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgery
Authors: Islam Omar
Brijesh Madhok
Chetan Parmar
Omar Khan
Michael Wilson
Kamal Mahawar
Publication date: 01-06-2021
Publisher: Springer US
Keywords: Bariatric Surgery
Bariatric Surgery
Published in: Obesity Surgery / Issue 6/2021
Print ISSN: 0960-8923
Electronic ISSN: 1708-0428
DOI: https://doi.org/10.1007/s11695-021-05330-z

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Analysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgery

Abstract

Background

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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