ObjectivesWe sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number ...of such accidents by making recommendations about possible training requirements.DesignSummaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination.SettingA total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013.Primary and secondary outcome measuresThe cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue.ResultsOverall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%).ConclusionsPoor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.
Purpose
Non-technical skills rating systems, which are designed to support surgical performance, have been introduced worldwide, but not officially in Japan. We performed a pilot study to evaluate ...the “non-technical skills for surgeons” (NOTSS) rating system in a major Japanese cancer center.
Methods
Upper gastrointestinal surgeons were selected as trainers or trainees. The trainers attended a master-class on NOTSS, which included simulated demo-videos, to promote consistency across the assessments. The trainers thereafter commenced observing the trainees and whole teams, utilizing the NOTSS and “observational teamwork assessment for surgery” (OTAS) rating systems, before and after their education.
Results
Four trainers and six trainees were involved in this study. Test scores for understanding human factors and the NOTSS system were 5.89 ± 1.69 and 8.00 ± 1.32 before and after the e-learning, respectively (mean ± SD,
p
= 0.010). The OTAS scores for the whole team improved significantly after the trainees’ education in five out of nine stages (
p
< 0.05). There were no differences in the NOTSS scores before and after education, with a small improvement in the total scores for the “teamwork and communication” and “leadership” categories.
Conclusion
These findings demonstrate that implementing the NOTSS system is feasible in Japan. Education of both surgical trainers and trainees would contribute to better team performance.
Abstract
Background
The past half century has seen the near eradication of transfusion-associated hazards. Intraoperative cell salvage while widely used still poses significant risks and hazards due ...to human error. We report on a case in which blood collected from a patient with lung cancer was mistakenly administered to a patient undergoing cardiac surgery who should have received his own collected blood. The initial investigation found that the cause of the patient harm was violations of procedures by hospital personnel. A detailed investigation revealed that not only violations were the cause, but also that the underlying causes included haphazard organizational policies, poor communication, workload and staffing deficiencies, human factors and cultural challenges.
Case presentation
On August 14, 2019, a 72-year-old male was admitted to our hospital for angina pectoris and multivessel coronary artery disease. Cardiac surgery was performed using an autologous salvage blood collection system, and there were no major problems other than the prolonged operation time. During the night after the surgery, when the patient’s blood pressure dropped, a nurse retrieved a blood bag from the ICU refrigerator that had been collected during the surgery and administered it at the physician's direction, but at this time neither the physician nor the nurse performed the required checking procedures. The blood administered was another patient's blood taken from another surgery the day before; an ABO mismatch transfusion occurred and the patient was diagnosed with DIC. The patient was discharged 65 days later after numerous interventions to support the patient. An accident investigation committee was convened to analyze the root causes and develop countermeasures to prevent a recurrence.
Conclusion
This adverse event occurred because the protocol for intraoperative blood salvage management was not clearly defined, and the procedure was different from the standard transfusion practices. We developed a new workflow based on a human factors grounded, systems-wide improvement strategy in which intraoperative blood collection would be administered before the patient leaves the operating room to completely prevent recurrence, instead of simply requiring front-line staff to do a double-check. Implementing strong systems processes can reduce the risk of errors, improve the reliability of the work processes and reduce the likelihood of patient harm occurring in the future.
Removal of midline paraventricular gliomas is difficult because of their deep localization and invasive character, requiring biopsy for pathologic diagnosis. This study aimed to assess the pathologic ...findings and clinical course of midline paraventricular gliomas diagnosed using a neuroendoscope.
This study was performed as a retrospective investigation using a neuroendoscope of 26 patients whose tumors were diagnosed as midline paraventricular gliomas. The main loci of the lesions were the thalamus (11 patients), tectum (6 patients), and other areas (9 patients). Of these 26 patients, 21 (81%) had accompanying obstructive hydrocephalus. Surgery was performed via the lateral ventricle using a flexible scope. For patients with obstructive hydrocephalus, we added endoscopic third ventriculostomy, septostomy, and/or plasty of the foramen of Monro. Pathologic diagnosis was determined according to hematoxylin-eosin staining and immunohistochemistry using anti-GFAP, anti-Ki-67, anti-H3-K27M, and anti-IDH1-R132H antibodies.
The pathologic diagnoses were grade I (5 patients), grade II (3 patients), grade III (6 patients), and grade IV (4 patients) gliomas. Six patients were diagnosed as having high-grade glioma, which was difficult to distinguish between grade III and grade IV. Two patients were undiagnosable. H3-K27M was strongly positive in 8 of 15 patients with high-grade glioma. All patients with high-grade gliomas died or received best supportive care within 2 years after surgery.
Neuroendoscopic surgery is useful for midline paraventricular gliomas in terms of the treatment of obstructive hydrocephalus, as well as pathologic diagnosis and genetic analysis, which are required under the World Health Organization 2016 classification.
•Neuroendoscope is useful for midline paraventricular gliomas in diagnosis and treatment of obstructive hydrocephalus.•All high-grade patients died or received best supportive care within 2 years after surgery.•H3-K27M was strongly positive in 8 cases among 15 cases of high-grade glioma.
Unilateral hydrocephalus (a situation whereby one lateral ventricle is dilated) is a relatively rare condition. Many cases result from morphological obstruction of the foramen of Monro (congenital ...atresia, tumor, cyst, etc.) or membranous obstruction of the foramen of Monro (inflammation due to infection or hemorrhage). However, we report a case of a 4-year-old boy who presented with unilateral hydrocephalus without an obvious obstruction of the foramen of Monro. It was discovered accidentally while exploring the cause of optic disc edema. We performed a neuroendoscopic exploration before surgery because of the unilateral hydrocephalus caused by a membranous obstruction of the foramen of Monro. However, neuroendoscopic observation revealed stenosis of the foramen of Monro, covered by the choroid plexus, suggesting some check valve function. After endoscopic septostomy, there was a marked dilatation of one lateral ventricle and relieve of the optic disc edema. In this case, we demonstrated the pathophysiology of unilateral hydrocephalus and the usefulness of endoscopic treatment.
To retrospectively evaluate the effectiveness of fractionated stereotactic radiotherapy (FSRT) for craniopharyngioma.
Between 1999 and 2005, 16 patients with craniopharyngioma were referred to Tokyo ...Medical University Hospital. They received FSRT alone after histologic confirmation by needle biopsy and underwent cyst drainage via endoscopy. The median prescription dose fraction was 30 Gy in six fractions. All patients except 1 were followed up until December 2009 or death.
The median follow-up period was 52 months (range, 4-117 months). Of the 17 patients, 3 experienced recurrence 4 to 71 months after FSRT. The 3-year local control rate was 82.4%. One patient died of thyroid cancer, and the 3-year survival rate was 94.1%. Eight patients had improved visual fields at a median of 2.5 months after FSRT, but hormonal functions did not improve in any patient.
FSRT after cyst drainage seems to be safe and effective for patients with craniopharyngiomas, and it may be a safe alternative to surgery.
In 1998, the Guidelines Committee on the Management of Severe Head Injury was established by the Japan Society of Neurotraumatology, and performed a critical review of national and international ...studies published over the past 10 years. The guidelines were first published in 2000 based on the results of this literature review and the Committee consensus, and the 2nd revised edition was published in 2006. This English version of the 2nd edition of the guidelines is intended to promote its concepts and use worldwide.
Functioning pituitary adenomas may exhibit spontaneous remission after pituitary apoplexy usually in association with hypopituitarism. We report two patients who presented with sudden headache and ...double vision, showed a ring-enhanced sellar tumor on MRI, underwent transsphenoidal surgery that revealed a coagulation necrotic adenoma without massive hemorrhage, and showed normal pituitary function after the surgery. Definitive diagnoses were made based on immunohistochemistry of the necrotic cells. The findings were consistent with the presence of selective infarct of a GH adenoma and a prolactinoma that had led to remission of acromegaly and menstrual disturbance, respectively, without pituitary insufficiency. In contrast to hemorrhagic apoplexy, infarctive apoplexy tends to affect only the tumor and thus presents with mild symptoms and lack pituitary deficiencies.
A 32-year-old man presented with a rapidly progressive decrease in visual acuity and diplopia. Magnetic resonance imaging (MRI) revealed a suprasellar cystic mass extending to the upper part of the ...clivus. The content of this cyst showed a slightly higher signal intensity than that of his cerebrospinal fluid (CSF) on T1-weighted images. The cyst stretched the pituitary stalk, but a normal pituitary signal was observed. The cyst wall was maximally resected under neuroendoscopy, which yielded fluid contents that were white and mucous like, with a carcinoembryonic antigen (CEA) level 1,400 ng/ml or higher. On light microscopy, one to two layers of epithelial cells with cylindrical nuclei on loose connective tissue lined the cyst cavity. These cells were positive for periodic acid-Schiff, CEA, and cytokeratin 7 and negative for cytokeratin 20. On electron microscopy, epithelial cells showed many short microvilli with coating material. The cytoplasm was rich in electron-dense material, and dense intercellular adhesion was observed, but neither goblet cells nor cilia were present. On the basis of MRI features, cytokeratin expression patterns and electron microscopic findings, the patient was considered to have a suprasellar endodermal cyst derived from Seessel’s pouch.
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