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Characteristics of Medical Adverse Events/Near Misses Associated With Laparoscopic/Thoracoscopic Surgery

A Retrospective Study Based on the Japanese National Database of Medical Adverse Events

Abe, Takashige MD, PhD*; Murai, Sachiyo*; Nasuhara, Yasuyuki MD, PhD; Shinohara, Nobuo MD, PhD*

doi: 10.1097/PTS.0000000000000422
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Objectives The aim of this study was to clarify the characteristics of adverse events/near misses during laparoscopic/thoracoscopic surgery.

Methods Using relevant key words for minimally invasive surgeries, 540 records were identified in the database of the Japan Council for Quality Health Care. After data review and the classification of adverse events, 746 events associated with laparoscopic (laparo group) and/or thoracoscopic (thoraco group) surgery were identified. We calculated the frequency of each event, compared the frequency regarding recurrent events, and evaluated the types of event that had resulted in deaths between the 2 groups.

Results There were 582 events in the laparo group, 159 in the thoraco group, and 5 in those undergoing combined surgery. Overall, injury of other organs (11.4%, 85/746), retention of a foreign body (9.1%, 68/746), breakage/failure of medical equipment or devices (6.2%, 46/746), massive bleeding (5.9%, 44/746), misperception of anatomy (5.6%, 42/746), and vascular injury (4.8%, 36/746) were frequently reported. There were marked differences in the frequency of injury of other organs (laparo group: 13.4%, 78/582; thoraco group: 4.4%, 7/159), massive bleeding (laparo group: 3.4%, 20/582; thoraco group: 14.5%, 23/159), and vascular injury (laparo group: 2.6%, 15/582; thoraco group: 12.6%, 20/159) between the 2 groups. Among the 56 patient-death reports, 132 adverse events were identified. In the thoraco group, bleeding events were frequently observed, whereas in the laparo group, various categories of events were noted.

Conclusions We observed recurrent incidents and differences in the frequency between the 2 groups. Surgeons should keep in mind these characteristics. Retention of a foreign body and the breakage/malfunctioning of instruments might be reduced by the introduction of specialized checklists.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

From the *Department of Urology, Hokkaido University Graduate School of Medicine; and †Division of Hospital Safety Management, Hokkaido University Hospital, Sapporo, Japan.

Correspondence: Takashige Abe, MD, PhD, Department of Urology, Hokkaido University Graduate School of Medicine, North-15, West-7, North Ward, Sapporo 060-8638, Japan (e-mail: takataka@rf6.so-net.ne.jp).

The authors disclose no conflict of interest.

This work was supported by a Grant-in-Aid for Scientific Research (C) (KAKENHI no. 26460853) from the Japan Society for the Promotion of Science.

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