Articles Posted in Surgical Errors & Injuries

surgery-688380_640-300x200A Chicago-based startup has created a simulation technology that promises to act as a safe and realistic model for the training of surgical residents and surgeons.

The startup, founded by a mother-daughter duo, claims that they’ve created an accessible and realistic surgical model for medical students and residents. The goal is to reduce the incidence of medical errors by allowing students to practice on a simulation model that more accurately mimics the actual surgical room conditions in which residents and surgeons will later work. The company plans to have its first product, a liver surgical model that can be used for simulation of liver transplants, available on the market in the next three months.

According to the founders of PraxiCut, there are several obstacles that medical and surgical residents face when asked to practice surgery in patients. Most surgical simulations occur on cadavers, and there are several limitations involved in operating on those who have already died. For instance, there is no bleeding involved, and surgical residents may not fully appreciate the kind of complications and dangers that arise when there is sudden or unexpected bleeding in the middle of surgery. Also, due to ethical concerns, operating on animals is slowly being phased out in many hospitals.

surgical lights shining brightUndergoing surgery is a traumatic experience for all. No matter the type of surgery or how minor the surgery might be, patients often feel some trepidation before being wheeled into the operating room. Everyone enters an operating room expecting that they will be healthier when they leave. That isn’t necessarily how it turns out, however. In too many instances, patients suffer injuries as a result of serious surgical errors that are made in the operating room.

It may seem surreal that errors should occur in an operating room, where there are fairly large numbers of staff members, all working together in seemingly perfect coordination. After all, a surgical room is one location where protocols and procedures should be followed strictly with each and every procedure. Unfortunately, that is always not the case. Miscommunication between staff members, failure to adhere to protocols and checklists, failure to follow basic medical guidelines, and other failures place patients at risk of injuries due to surgical errors.

Surgical errors can occur due to a number of causes. Lack of adequate planning for the surgery is just one of the causes of medical errors. In addition, there are basic simple steps that should be followed with each surgical procedure. As one example, surgical staff must mark the part of the body to operate on before the surgery.  When these steps are not taken, there is an increased risk to patient safety.

robot surgery warningsSeveral hospitals around Indiana have begun to invest in robotic surgeries.  The move is made because of perceived increased efficiency and a range of other benefits. However, there is increasing proof that there are risks involved in these technical surgeries that we haven’t yet fully understood.

Recently, researchers analyzed reports from the Food and Drug Administration documenting more than 10,000 incidents involving robotic surgeries. These incidents resulted in 144 patient fatalities, and more than 1,300 injuries between 2000 and the 2013 – nearly 1,000 injuries a year.  Many of these errors involved pieces of medical tools falling into the patient, which accounted for more than 14% of the incidents. In more than 10% of the incidents electrical sparking caused an adverse incident while the robotic surgery was in progress. In more than 8% of the cases, the robots made sudden unintended movements that caused injuries to the patient. Unintended movements seem to be the most likely to cause serious injuries. They resulted in approximately 50 injuries and at least two fatalities.

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Brain Injury HelmetIndiana’s high school and college football season is underway and thousands of youth take the field in competitions of shear, brute force and strength. For many fans, football is a highlight of the sports seasons, with crisp autumn air, pep bands playing the school fight songs, and school spirit on full display.  Unfortunately for many players this season, as in seasons past, these young people will be subject to life-altering injuries; not the least of these being a traumatic head injury (TBI).

News reports increasingly inform the public of another player who is sidelined by an major injury or even death.  USA Today focused on this issue last year in their own investigation but the trouble has not diminished, even with increased scrutiny.  In fact, the problem is growing into epidemic proportions and the trouble is greatest at the high school level.  As the USA Today article points out, “High school football players suffer three times as many catastrophic injuries as college players — meaning deaths, permanent disability injuries, neck fractures and serious head injuries, among other conditions, according to a 2007 study in the American Journal of Sports Medicine.”  This report notes that nearly all the serious injuries came from either being tackled or tackling.

In a recent Frontline investigation, it was determined that more than 80% of football players examined after their death were found to have a severe form of brain chronic injury known as Chronic Traumatic Encephalopathy or CTE.  This was true whether they played at the elite professional level, college, or even high school level of the sport.

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surgery%20equipment.jpgIn spite of advancements in medical technology and statistics that clearly reveal that the vast majority of medical errors that occur across the country every year are preventable, these errors continue to occur. The Joint Commission recently released a report which analyses the top causes of the most common errors.

The report focused on the top causes of sentinel events that include anesthesia- related events, operative or postoperative complications, retention of surgical objects, and wrong patient /wrong procedure events. For instance, the joint commission reports that 62% of the sentinel events were related to anesthesia care, while other causes included human factors, lack of assessment, failures of communication, leadership factors, physical environment, medication errors, continuum of care and care planning.
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scalple.jpgSurgical checklists, like the one developed by the World Health Organization, are highly recommended to help reduce the risk of surgical errors and complications. However according to a new study, surgical checklists are often not used properly, or not used at all. Noncompliance is a huge problem in the healthcare industry and as a result, patients are frequently exposed to the risk of serious or fatal errors.

According to a study that was conducted by researchers from the Columbia University School of Nursing, many hospitals don’t even have a surgical checklist to prevent infections, while those that do implement checklists are unable to make sure that these are being followed completely. As many as one in 10 hospital Intensive Care Units did not implement the checklist for the prevention of central line-associated blood stream infections. These are potentially fatal infections that result from the contamination of the central lines that are used to deliver nutrition and drugs to a patient in an ICU. One in four hospitals did not even have a checklist for preventing ventilator-associated pneumonia, which is one of the most common fatal hospital-acquired infections. Even when the hospital did have a checklist, the checklists were only followed approximately 50% of the time.
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iv%20bag.jpgSome of the biggest medical hazards in 2014 involve alarm fatigue, robotic surgery complications, and medication errors from infusion pumps. According to the Emergency Care Research Institute, which has just released its list of the top 10 medical tech hazards for 2014, the biggest hazard we need to look out for this year is alarm fatigue.

The list includes a number of serious medical technology hazards that hospitals need to look out for the coming year. Some hazards featured on the list with alarming regularity every year, while other problems are fairly new; although the Institute believes that these problems have the potential to become serious hazards in the coming year. The good news is that all of these risks are entirely preventable.

Topping the list in 2014 is an alarm fatigue. This problem has already received a fair amount of attention in this blog. Alarm fatigue is a serious risk to patient care and refers to the kind of distractions that plague nurses who are exposed to dozens of medical alarms drinking continuously throughout their working day. At some point in time, nurses become desensitize to the frequent nature of these alarms and choose to simply ignore them, or worse, may unintentionally miss out on important alarms. This is a serious patient safety risk, and the only feasible solution is to reduce the number of medical alarms by eliminating those that may not be completely necessary.
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surgery.jpgLast year alone, doctors across the country performed more than 350,000 surgical procedures using the Da Vinci robotic surgery system. In spite of the prolific use of robotic systems, the federal administration still lags behind in collecting accurate information about the use of these devices and surgical errors resulting from such use.

According to a report recently published in Bloomberg, the Food and Drug Administration (FDA) is failing miserably in calculating accurate data about the use of robotic surgery systems in the United States. The FDA maintains a database of all injury reports, caused by the surgical system but the Agency has no legal authority to force hospitals or doctors to report any errors that occur with the use of the surgery systems or any injuries that result. Hospitals are required to report the number of errors that occur when using the systems, but they very often fail to comply with those rules. As a result, whatever data is contained in the FDA database is woefully inadequate.
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wheelchair1.jpgAccording to new data on medical errors in Indiana for the year 2012, as reported by the Indiana State Department of Health, bedsores and surgical errors constitute some of the most frequent errors reported by hospitals in 2012.

There were 30 incidents involving bedsores reported in 2012. That was a drop from 41 errors reported in 2011. According to the report, the average number of bedsores reported every year is approximately 30, and severe bedsores, or pressure ulcers, have been the most frequently reported medical errors in six of the seven years since the Indiana State Department of Health began compiling the Medical Errors Report.

Overall, a total of 2,100 medical errors were reported in 2012. That was the same number reported back in 2011.
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surgery%20phones.jpgIt’s fairly common for doctors, nurses and other medical professionals to use smart phones in the operating room (OR). They may check medication dosages or search for important medical information. However, sometimes, those cell phones are used for non-medical purposes and a nursing group says that when that happens, there’s a serious risk of medical errors.

There are a number of reasons why doctors and nurses may use cell phones in a operating room. For instance, sometimes a doctor may need to text the patient’s relatives for important information, or may need to look up information about the disease. There’s no doubt that the use of smart phones is important in the OR.

However, in an increasing number of cases, doctors as well as nurses are using smart phones for non-medical reasons inside the operating room. According to a report by NPR, you can now find medical personnel chatting, looking at Facebook status updates, playing games, and performing a variety of other non-medical-related activities using their smart phones in the operating room.
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