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dc.contributor.authorMadhok, Brijesh
dc.date.accessioned2021-03-18T10:28:41Z
dc.date.available2021-03-18T10:28:41Z
dc.date.issued2021-03
dc.identifier.citationObes Surg. 2021 Mar 5. doi: 10.1007/s11695-021-05330-z. Epub ahead of print.en
dc.identifier.urihttps://orda.derbyhospitals.nhs.uk/handle/123456789/2410
dc.description.abstractBackground: 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.en
dc.language.isoenen
dc.subjectBariatric Surgeryen
dc.subjectLearning Themesen
dc.subjectMedical Claimsen
dc.subjectPatient Safetyen
dc.titleAnalysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgeryen
dc.typeArticleen


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