Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.
Identifieur interne : 000169 ( Main/Exploration ); précédent : 000168; suivant : 000170Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.
Auteurs : Kholoud Houssaini [Maroc] ; Oumayma Lahnaoui [Maroc] ; Amine Souadka [Maroc] ; Mohamed-Anass Majbar [Maroc] ; Abdelilah Ghanam [Maroc] ; Brahim El Ahmadi [Maroc] ; Zakaria Belkhadir [Maroc] ; Leila Amrani [Maroc] ; Raouf Mohsine [Maroc] ; Amine Benkabbou [Maroc]Source :
- Patient safety in surgery [ 1754-9493 ] ; 2020.
Abstract
Background
The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.
Methods
This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: "Patient", "Tasks", "Individual staff", "Team", "Work environment", and "Management and Institutional context". Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.
Results
In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.
Conclusion
A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.
DOI: 10.1186/s13037-020-00261-7
PubMed: 33014137
PubMed Central: PMC7526378
Affiliations:
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wicri:step="Curation">000097</idno><idno type="wicri:Area/Main/Exploration">000097</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en">Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.</title><author><name sortKey="Houssaini, Kholoud" sort="Houssaini, Kholoud" uniqKey="Houssaini K" first="Kholoud" last="Houssaini">Kholoud Houssaini</name><affiliation wicri:level="3"><nlm:affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="Lahnaoui, Oumayma" sort="Lahnaoui, Oumayma" uniqKey="Lahnaoui O" first="Oumayma" last="Lahnaoui">Oumayma Lahnaoui</name><affiliation wicri:level="3"><nlm:affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="Souadka, Amine" sort="Souadka, Amine" uniqKey="Souadka A" first="Amine" last="Souadka">Amine Souadka</name><affiliation wicri:level="3"><nlm:affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="Majbar, Mohamed Anass" sort="Majbar, Mohamed Anass" uniqKey="Majbar M" first="Mohamed-Anass" last="Majbar">Mohamed-Anass Majbar</name><affiliation wicri:level="3"><nlm:affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="Ghanam, Abdelilah" sort="Ghanam, Abdelilah" uniqKey="Ghanam A" first="Abdelilah" last="Ghanam">Abdelilah Ghanam</name><affiliation wicri:level="3"><nlm:affiliation>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="El Ahmadi, Brahim" sort="El Ahmadi, Brahim" uniqKey="El Ahmadi B" first="Brahim" last="El Ahmadi">Brahim El Ahmadi</name><affiliation wicri:level="3"><nlm:affiliation>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="Belkhadir, Zakaria" sort="Belkhadir, Zakaria" uniqKey="Belkhadir Z" first="Zakaria" last="Belkhadir">Zakaria Belkhadir</name><affiliation wicri:level="3"><nlm:affiliation>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="Amrani, Leila" sort="Amrani, Leila" uniqKey="Amrani L" first="Leila" last="Amrani">Leila Amrani</name><affiliation wicri:level="3"><nlm:affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="Mohsine, Raouf" sort="Mohsine, Raouf" uniqKey="Mohsine R" first="Raouf" last="Mohsine">Raouf Mohsine</name><affiliation wicri:level="3"><nlm:affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author><author><name sortKey="Benkabbou, Amine" sort="Benkabbou, Amine" uniqKey="Benkabbou A" first="Amine" last="Benkabbou">Amine Benkabbou</name><affiliation wicri:level="3"><nlm:affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</nlm:affiliation><country xml:lang="fr">Maroc</country><wicri:regionArea>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat</wicri:regionArea><placeName><settlement type="city">Rabat</settlement><region nuts="2">Rabat-Salé-Kénitra</region></placeName></affiliation></author></analytic><series><title level="j">Patient safety in surgery</title><idno type="ISSN">1754-9493</idno><imprint><date when="2020" type="published">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p><b>Background</b></p><p>The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.</p></div><div type="abstract" xml:lang="en"><p><b>Methods</b></p><p>This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: "Patient", "Tasks", "Individual staff", "Team", "Work environment", and "Management and Institutional context". Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.</p></div><div type="abstract" xml:lang="en"><p><b>Results</b></p><p>In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.</p></div><div type="abstract" xml:lang="en"><p><b>Conclusion</b></p><p>A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.</p></div></front></TEI><pubmed><MedlineCitation Status="PubMed-not-MEDLINE" Owner="NLM"><PMID Version="1">33014137</PMID><DateRevised><Year>2020</Year><Month>11</Month><Day>14</Day></DateRevised><Article PubModel="Electronic-eCollection"><Journal><ISSN IssnType="Print">1754-9493</ISSN><JournalIssue CitedMedium="Print"><Volume>14</Volume><PubDate><Year>2020</Year></PubDate></JournalIssue><Title>Patient safety in surgery</Title><ISOAbbreviation>Patient Saf Surg</ISOAbbreviation></Journal><ArticleTitle>Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.</ArticleTitle><Pagination><MedlinePgn>36</MedlinePgn></Pagination><ELocationID EIdType="doi" ValidYN="Y">10.1186/s13037-020-00261-7</ELocationID><Abstract><AbstractText Label="Background" NlmCategory="UNASSIGNED">The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.</AbstractText><AbstractText Label="Methods" NlmCategory="UNASSIGNED">This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: "Patient", "Tasks", "Individual staff", "Team", "Work environment", and "Management and Institutional context". Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.</AbstractText><AbstractText Label="Results" NlmCategory="UNASSIGNED">In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.</AbstractText><AbstractText Label="Conclusion" NlmCategory="UNASSIGNED">A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.</AbstractText><CopyrightInformation>© The Author(s) 2020.</CopyrightInformation></Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Houssaini</LastName><ForeName>Kholoud</ForeName><Initials>K</Initials><Identifier Source="ORCID">0000-0002-3454-1281</Identifier><AffiliationInfo><Affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Lahnaoui</LastName><ForeName>Oumayma</ForeName><Initials>O</Initials><AffiliationInfo><Affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Souadka</LastName><ForeName>Amine</ForeName><Initials>A</Initials><AffiliationInfo><Affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Majbar</LastName><ForeName>Mohamed-Anass</ForeName><Initials>MA</Initials><AffiliationInfo><Affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Ghanam</LastName><ForeName>Abdelilah</ForeName><Initials>A</Initials><AffiliationInfo><Affiliation>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>El Ahmadi</LastName><ForeName>Brahim</ForeName><Initials>B</Initials><AffiliationInfo><Affiliation>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Belkhadir</LastName><ForeName>Zakaria</ForeName><Initials>Z</Initials><AffiliationInfo><Affiliation>Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Amrani</LastName><ForeName>Leila</ForeName><Initials>L</Initials><AffiliationInfo><Affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Mohsine</LastName><ForeName>Raouf</ForeName><Initials>R</Initials><AffiliationInfo><Affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Benkabbou</LastName><ForeName>Amine</ForeName><Initials>A</Initials><AffiliationInfo><Affiliation>Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.</Affiliation><Identifier Source="GRID">grid.31143.34</Identifier><Identifier Source="ISNI">0000 0001 2168 4024</Identifier></AffiliationInfo></Author></AuthorList><Language>eng</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList><ArticleDate DateType="Electronic"><Year>2020</Year><Month>09</Month><Day>29</Day></ArticleDate></Article><MedlineJournalInfo><Country>England</Country><MedlineTA>Patient Saf Surg</MedlineTA><NlmUniqueID>101319176</NlmUniqueID><ISSNLinking>1754-9493</ISSNLinking></MedlineJournalInfo><CommentsCorrectionsList><CommentsCorrections RefType="ErratumIn"><RefSource>Patient Saf Surg. 2020 Nov 12;14(1):41</RefSource><PMID Version="1">33292471</PMID></CommentsCorrections></CommentsCorrectionsList><KeywordList Owner="NOTNLM"><Keyword MajorTopicYN="N">Aggregate root cause analysis</Keyword><Keyword MajorTopicYN="N">Liver resection</Keyword><Keyword MajorTopicYN="N">Patient safety</Keyword><Keyword MajorTopicYN="N">Postoperative complications</Keyword></KeywordList><CoiStatement>Competing interestsThe authors declare that they have no competing interests.</CoiStatement></MedlineCitation><PubmedData><History><PubMedPubDate PubStatus="received"><Year>2020</Year><Month>07</Month><Day>15</Day></PubMedPubDate><PubMedPubDate PubStatus="accepted"><Year>2020</Year><Month>09</Month><Day>17</Day></PubMedPubDate><PubMedPubDate PubStatus="entrez"><Year>2020</Year><Month>10</Month><Day>5</Day><Hour>6</Hour><Minute>17</Minute></PubMedPubDate><PubMedPubDate PubStatus="pubmed"><Year>2020</Year><Month>10</Month><Day>6</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate 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IdType="pubmed">32251622</ArticleId></ArticleIdList></Reference></ReferenceList></PubmedData></pubmed><affiliations><list><country><li>Maroc</li></country><region><li>Rabat-Salé-Kénitra</li></region><settlement><li>Rabat</li></settlement></list><tree><country name="Maroc"><region name="Rabat-Salé-Kénitra"><name sortKey="Houssaini, Kholoud" sort="Houssaini, Kholoud" uniqKey="Houssaini K" first="Kholoud" last="Houssaini">Kholoud Houssaini</name></region><name sortKey="Amrani, Leila" sort="Amrani, Leila" uniqKey="Amrani L" first="Leila" last="Amrani">Leila Amrani</name><name sortKey="Belkhadir, Zakaria" sort="Belkhadir, Zakaria" uniqKey="Belkhadir Z" first="Zakaria" last="Belkhadir">Zakaria Belkhadir</name><name sortKey="Benkabbou, Amine" sort="Benkabbou, Amine" uniqKey="Benkabbou A" first="Amine" last="Benkabbou">Amine Benkabbou</name><name sortKey="El Ahmadi, Brahim" sort="El Ahmadi, Brahim" uniqKey="El Ahmadi B" first="Brahim" last="El Ahmadi">Brahim El Ahmadi</name><name 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