Overview and Implications
Surgery and other invasive procedures carry risk of complication and mortality (Magee et al., 2018). Unintentional or accidental cuts, punctures or perforations can occur in both surgical and medical procedures. A 10-year review of medico-legal cases in Canada between 2004 and 2013 found that incidents of
laceration, puncture, hemorrhage and burns accounted for 66 per cent of surgical incidents reported to the Canadian Medical Protective Association and 44 per cent of surgical incidents reported to the Healthcare Insurance Reciprocal of Canada (Canadian Medical Protective Association (CMPA) & Healthcare Insurance Reciprocal of Canada (HIROC), 2016). A review of high harm events reported to Pennsylvania Patient Safety Reporting System (PA-PSRS) as a complication following surgery or invasive procedure, revealed that more than a third of the cases (n=34/101) involved punctures, lacerations, or tears (Magee et al., 2018). A review of a sample of reports submitted to PA-PSRS involving unintended lacerations or punctures during surgery found that 78 per cent of the reports described injuries to the colon (mostly during colonoscopy), the bladder (mostly during hysterectomy), or the uterus (mostly during hysteroscopy).
A search of publicly available patient safety alerts revealed the following examples of accidental lacerations and punctures:
- bladder laceration during a cesarean section (Wallace, 2016)
- splenic laceration during a colonoscopy which required an emergent splenectomy (Magee et al., 2018)
- pulmonary artery laceration during robotic-assisted lobectomy (Dubeck, 2014)
- injury to the heart and stomach during the placement of the chest tubes (Pennsylvania Patient Safety Authority, 2007)
- tear to a child's atrium upon post-operative removal of an atrial pacing wire (McClurken, 2006)
- stomach perforation and subsequent needle decompression resulted in a lacerated liver, during an endoscopy procedure (Manitoba Health, Healthy Living & Seniors (MHHLS), 2017)
- rectal perforation related to use of a glycerin enema (Japan Council for Quality Health Care, 2007)
Potential causes of accidental laceration/puncture
A search of patient safety reporting/alert systems revealed that the potential causes of accidental laceration/puncture during a medical or surgical procedure may include:
Distraction is a threat to patient safety. Distraction is defined as having one's attention drawn or directed "to a different object or in different directions at the same time." The impact of distraction is influenced by multiple variables, including the characteristics of the primary task, the distractions themselves, and the environment. Distractions are expected in healthcare, due to the constant communication and coordination that is required. It is important to note that that distraction due to interruptions that are purposeful and share important information may improve care by appropriately refocusing attention and improving problem identification, collaboration, and communication. However, distractions due to non-purposeful interruptions or operational failures that impair performance and contribute to error are concerning and risk patient safety.
Distraction is particularly detrimental to performance of complex tasks that require high levels of cognitive processing. Such tasks are encountered often in the operating room (OR) due to the complex nature of each work system factor: the physical environment, teamwork and communication, tools and technology, tasks and workload, and organizational processes. Even minor distractions in the OR can have a cascade effect that ultimately results in major events and patient harm. Engagement of surgeons and multidisciplinary teams is necessary to address the problem of distractions in the OR (Feil, 2014).
From simple lighting to technologically-advanced medical devices and surgical instruments, medical equipment is integral to the delivery of quality patient care. Although the potential for patient safety incidents related to equipment malfunction or failure exists, such incidents can be difficult to predict or prevent.
During a CMPA review of medico-legal cases arising from equipment problems, three predominant equipment-related issues were identified:
- equipment malfunctions and failures;
- wrong application, improper use, or unapproved use of equipment during a procedure or during medication delivery by physicians and other healthcare professionals; and
- new equipment issues, including training and supervision deficiencies.
Patient injury resulting from equipment-related misadventures was a recurrent theme. Burns,
lacerations, and perforations were the most prevalent injuries.
Examples of equipment deficiencies during a procedure include:
- breakage of surgical instruments (e.g. needles, scalpel blades)
- malfunctioning equipment or equipment failure (e.g. misfiring of a stapler)
- defective equipment (e.g. rupture of a catheter balloon)
- detachment of equipment (e.g. ureteric stone basket)
Central Line Related
Central lines are widely and effectively used in clinical medicine. The cannulation of major veins allows physicians to manage and monitor inpatients and outpatients. The ability to place these lines safely crosses many specialties and includes trainees. Complications such as vessel
laceration, pneumothorax, neurological injury,
atrial perforation, retroperitoneal hematoma, venous thrombosis, and infection are infrequent, but can have serious consequences for patients (CMPA, 2011).
Fetal Lacerations Associated with Caesarean Section
The Pennsylvania Health Authority has reported on fetal lacerations, associated with cesarean sections. Most of the lacerations were reported to be superficial, however some have required suturing and/or plastic surgery intervention. Risk factors identified with these patient safety incidents were: ruptured membranes prior to C-section, low transverse uterine incision, active labour, emergency/urgent C-section, inexperience of the surgeon (Pennsylvania Patient Safety Authority, 2004a).
Lacerations from scissor-related injuries
Lacerations have resulted from scissor-related injuries obtained during the provision of care. Scissor-related injuries have ranged from superficial nicks to lacerations requiring closure with adhesive strips or sutures. An analysis of the circumstances involved in these reports indicates the following patterns. Difficulty removing adhesive tape (during IV or dressing changes) was documented in 38 per cent of the reports, while removing patient identification bands was involved in 31 per cent of the reports. Other factors cited in these reports included: bandage removal; obstructed view of the area in which scissors were used; and use of scissors when other equipment may have been safer (such as using scissors to remove excessive hair from an area) (Pennsylvania Patient Safety Advisory, 2004b).
The insertion of a chest tube is required to remove air, blood, pus or fluid from the pleural cavity, and is used in patients with a collapsed lung, malignancies, chest trauma or after surgery. Improper insertion of a chest drain may puncture major organs such as heart, lungs, liver and spleen, causing significant harm to the patient. Common themes from a review of incidents include: supervision of junior doctors and levels of experience of clinicians inserting chest drains; failure to follow manufacturer's instructions; improper selection of the site of insertion, poor positioning; improper use of dilators; anatomical anomalies and the patient's clinical condition; inadequate pre procedural or post placement imaging; lack of knowledge of existing clinical guidelines for chest tube insertion (National Patient Safety Agency (NPSA), 2008).
Reduce the incidence of inadvertent laceration/puncture.
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