The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland, 2010
A surgical fire is potentially devastating for a patient. Fire has been recognised as a potential... more A surgical fire is potentially devastating for a patient. Fire has been recognised as a potential complication of surgery for many years. Surgical fires continue to happen with alarming frequency. We present a review of the literature and an examination of possible solutions to this problem. The PubMed and Medline databases from 1948 onwards were searched using the subject headings "operating rooms", "fire", "safety" and "safety management". "Surgical fire" was also searched as a keyword. Relevant references from articles were obtained. Fire occurs when the three elements of the fire triad, fuel, oxidiser and ignition coincide. Surgical fires are unusual in the absence of an oxygen-enriched atmosphere. The ignition source is most commonly diathermy but lasers carry a relatively greater risk. The majority of fires occur during head and neck surgery. This is due to the presence of oxygen and the extensive use of lasers. The risk of fir...
ABSTRACT Minimal access techniques have revolutionized surgery in the past 20 years. The concept ... more ABSTRACT Minimal access techniques have revolutionized surgery in the past 20 years. The concept originated in the early twentieth century and has now become part of standard surgical practice. The potential benefits of laparoscopy include reduced pain, functional impairment, inpatient stay and improved cosmesis. Recent technological advances have assisted in the application of the techniques to a paediatric population. There are now few paediatric surgical procedures remaining that have not been performed using minimal access techniques. The scope of laparoscopy in paediatric surgery encompasses neonatal surgery, thoracic surgery, gastrointestinal surgery, oncology and urology. The evidence base for laparoscopic surgery in childhood remains small but is growing. Laparoscopic surgery has been demonstrated to be at least equivalent to its open counterpart in some procedures and superior in a few. The indications for laparoscopic surgery continue to be further refined as more studies are published.
Minimal access techniques have revolutionised surgery in the past twenty years. The concept origi... more Minimal access techniques have revolutionised surgery in the past twenty years. The concept originated in the early twentieth century and has now become part of standard surgical practice.
Medical error has been increasingly recognized as a source of harm. The risk of harm can be even ... more Medical error has been increasingly recognized as a source of harm. The risk of harm can be even greater in cancer care with its potentially life-limiting disease and toxic treatments. When errors and adverse events occur, patients have a right to be informed and consistently report a desire to know about events in their care. Disclosure of errors is difficult for physicians for several reasons, including guilt and shame, the fear of litigation, concerns about the impact on the physician-patient relationship, and concerns about the impact on their personal reputation. Despite these difficulties, the experience of disclosure of medical error to date has shown that it can strengthen relationships, reduce litigation and the associated costs, and be beneficial to both the patient and physician. Disclosure can be approached in many of the same ways as any other difficult communication situations, with training and preparation helping to improve the process.
The Soave endorectal pullthrough is a commonly performed procedure for the definitive management ... more The Soave endorectal pullthrough is a commonly performed procedure for the definitive management of children with Hirschsprung's disease (HD). Anastomotic stricture is a recognised complication of this procedure . There are multiple causes for these strictures, circular anastomosis being one of them. There are techniques described which alter the shape of the anastomosis of the pulled through bowel to decrease the incidence of strictures. These are oblique [6] and heart-shaped anastomoses. We describe a new technique of oblique anastomosis where the pulled through bowel is anastomosed posteriorly 0.5 cm from the dentate line, and anteriorly 1.5 cm above this point. This oblique anastomosis is designed to lower the stricture rate. If a stricture does occur, an anastomosis near the anocutaneous junction on the posterior aspect also faciltates Y-V anoplasty. We present our experience using this technique. Seventeen consecutive children underwent the procedure at our institution between 2003 and 2006. Only one child developed an anastomotic stricture requiring anal dilatation.
Purpose: The relationship between congenital abdominal wall defects (AWDs) and undescended testes... more Purpose: The relationship between congenital abdominal wall defects (AWDs) and undescended testes (UDTs) is poorly defined. We report a study of infants with AWD and UDT. Methods: Hospital records of newborns with AWD managed during 1998 to 2008 were reviewed. Data analyzed included nature of AWD, position of the testes at birth, final position of the testes, and surgical management. Results: A total of 218 newborns with AWD were identified; 106 (49%) were boys. Of 79 boys with gastroschisis, 26 (33%) had UDT involving 35 testes. Of 27 with exomphalos, 6 (22%) had UDT involving 11 testes. Prolapsed testes were placed in the abdomen at AWD repair, whereas others were observed for "spontaneous" descent. Of 35 UDT in gastroschisis infants, 18 descended spontaneously, and 10 required orchidopexy. Three boys underwent laparoscopy for impalpable testes, 2 underwent orchidectomy, and 1 had bilaterally absent testes. Three cases await orchidopexy. In exomphalos boys with 11 UDTs, 1 gonad descended spontaneously, and 6 had groin exploration (1 absent testis and 5 orchidopexies). Two boys await orchidopexy, and 1 boy (bilateral impalpable testes) was lost to follow-up. Conclusion: Abdominal wall defects are strongly associated with UDT. In boys with gastroschisis, spontaneous descent of the testes may be anticipated in 50% of cases. In those with exomphalos, orchidopexy should be scheduled.
Having reported that 18% of children discontinue use of the antegrade continence enema (ACE) afte... more Having reported that 18% of children discontinue use of the antegrade continence enema (ACE) after 5 years, we aimed to determine long-term use after an ACE procedure. A postal/telephone questionnaire was conducted. Subjects were consecutive children undergoing an ACE between 1993 and 1999. Outcome measures were use of ACE, reasons for nonuse, complications, and overall satisfaction. Of 84 eligible subjects, data were available on 61 (73%) aged 22.4 years (15.5-35.1 years). Underlying diagnoses included spina bifida (n = 27), anorectal malformations (n = 18), constipation (n = 11), Hirschsprung's disease (n = 1), sacral agenesis (n = 2), and trauma/tumor (n = 2). Follow-up was 11.02 years (8.34-14.39 years). Thirty-six (59%) of 61 patients were still using their ACE. Reasons for nonuse were lack of effectiveness (n = 14), complications (n = 5), psychologic issues (n = 2), and poor compliance (n = 2). There was no association between diagnosis and nonuse (chi(2), P = .63). In those still using ACE, the overall satisfaction score was 4.1 (1-5). Several individuals reported feeling abandoned on becoming adults and losing the support they had in childhood. There is a late "failure" rate for the ACE procedure. However, satisfaction was high among those still using the ACE. This study further emphasizes the need for robust transitional care arrangements.
International Journal for Quality in Health Care, 2010
Purpose. Adverse events are increasingly recognized as a source of harm to patients. When such ha... more Purpose. Adverse events are increasingly recognized as a source of harm to patients. When such harm occurs, problems arise in communicating the situation to patients and their families. We reviewed the literature on disclosure across individual and international boundaries, including patients', healthcare professionals' and other stakeholders' perspectives in order to ascertain how the needs of all groups could be better reconciled.
Nasogastric tube insertion is a common clinical procedure carried out by doctors and nurses in NH... more Nasogastric tube insertion is a common clinical procedure carried out by doctors and nurses in NHS hospitals daily. For the last 30 years, there have been reports in the medical literature of deaths and other harm resulting from misplaced nasogastric tubes, most commonly associated with feed entering the pulmonary system. In 2005 the National Patient Safety Agency in England assembled reports of 11 deaths and one incident of serious harm from wrong insertion of nasogastric tubes over a two-year period. The agency issued a safety alert setting out evidence-based practice for checking tube placement. In the two and a half years following this alert the problem persisted with a further five deaths and six instances of serious harm due to nasogastric tube misplacement. This is a potentially preventable error but safety alerts advocating best practice do not appear to reliably reduce risk. Alternative solutions, such as standardising procedures, may be more effective.
Donaldson, Liam J; Rutter, Paul D; Ellis, Benjamin M; Greaves, Felix EC; Mytton, Oliver T; Pebody... more Donaldson, Liam J; Rutter, Paul D; Ellis, Benjamin M; Greaves, Felix EC; Mytton, Oliver T; Pebody, Richard G; Yardley, Iain E.
Objective To establish mortality from pandemic A/H1N1 2009 influenza up to 8 November 2009. Desig... more Objective To establish mortality from pandemic A/H1N1 2009 influenza up to 8 November 2009. Design Investigation of all reported deaths related to pandemic A/H1N1 in England. Setting Mandatory reporting systems established in acute hospitals and primary care. Participants Physicians responsible for the patient. Main outcome measures Numbers of deaths from influenza combined with mid-range estimates of numbers of cases of influenza to calculate age specific case fatality rates. Underlying conditions, time course of illness, and antiviral treatment.
To determine whether recent sexual intercourse might be a cause of microscopic haematuria in pati... more To determine whether recent sexual intercourse might be a cause of microscopic haematuria in patients referred to a urological unit following dipstick detection of urinary haemoglobin. Forty-eight volunteers (24 men and 24 women) consented to have heterosexual intercourse with their regular partner, and to provide samples of urine for testing before and from the first void on the morning after intercourse. After appropriate instruction, volunteers tested their own urine for the presence of blood using standard dipsticks. Any volunteer with haematuria either before or after intercourse was offered a standard haematuria assessment. The results were analysed using the chi-squared test. None of the volunteers tested positively for haematuria immediately before sexual intercourse; six of the 24 women (25%), but no men, became positive after intercourse (P < 0.01). Only one of the six women accepted the offer of a haematuria evaluation and no pathology was identified. These results suggest that up to a quarter of women develop microscopic haematuria as a direct result of sexual intercourse. A history of recent sexual intercourse should therefore be considered when assessing the clinical significance of microscopic haematuria in women.
Medical errors and adverse events are now recognized as major threats to both individual and publ... more Medical errors and adverse events are now recognized as major threats to both individual and public health worldwide. This review provides a broad perspective on major effective, established, or promising strategies to reduce medical errors and harm. Initiatives to improve safety can be conceptualized as a "safety onion" with layers of protection, depending on their degree of remove from the patient. Interventions discussed include those applied at the levels of the patient (patient engagement and disclosure), the caregiver (education, teamwork, and checklists), the local workplace (culture and workplace changes), and the system (information technology and incident reporting systems). Promising interventions include forcing functions, computerized prescriber order entry with decision support, checklists, standardized handoffs and simulation training. Many of the interventions described still lack strong evidence of benefit, but this should not hold back implementation. Rather, it should spur innovation accompanied by evaluation and publication to share the results.
The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland, 2010
A surgical fire is potentially devastating for a patient. Fire has been recognised as a potential... more A surgical fire is potentially devastating for a patient. Fire has been recognised as a potential complication of surgery for many years. Surgical fires continue to happen with alarming frequency. We present a review of the literature and an examination of possible solutions to this problem. The PubMed and Medline databases from 1948 onwards were searched using the subject headings "operating rooms", "fire", "safety" and "safety management". "Surgical fire" was also searched as a keyword. Relevant references from articles were obtained. Fire occurs when the three elements of the fire triad, fuel, oxidiser and ignition coincide. Surgical fires are unusual in the absence of an oxygen-enriched atmosphere. The ignition source is most commonly diathermy but lasers carry a relatively greater risk. The majority of fires occur during head and neck surgery. This is due to the presence of oxygen and the extensive use of lasers. The risk of fir...
ABSTRACT Minimal access techniques have revolutionized surgery in the past 20 years. The concept ... more ABSTRACT Minimal access techniques have revolutionized surgery in the past 20 years. The concept originated in the early twentieth century and has now become part of standard surgical practice. The potential benefits of laparoscopy include reduced pain, functional impairment, inpatient stay and improved cosmesis. Recent technological advances have assisted in the application of the techniques to a paediatric population. There are now few paediatric surgical procedures remaining that have not been performed using minimal access techniques. The scope of laparoscopy in paediatric surgery encompasses neonatal surgery, thoracic surgery, gastrointestinal surgery, oncology and urology. The evidence base for laparoscopic surgery in childhood remains small but is growing. Laparoscopic surgery has been demonstrated to be at least equivalent to its open counterpart in some procedures and superior in a few. The indications for laparoscopic surgery continue to be further refined as more studies are published.
Minimal access techniques have revolutionised surgery in the past twenty years. The concept origi... more Minimal access techniques have revolutionised surgery in the past twenty years. The concept originated in the early twentieth century and has now become part of standard surgical practice.
Medical error has been increasingly recognized as a source of harm. The risk of harm can be even ... more Medical error has been increasingly recognized as a source of harm. The risk of harm can be even greater in cancer care with its potentially life-limiting disease and toxic treatments. When errors and adverse events occur, patients have a right to be informed and consistently report a desire to know about events in their care. Disclosure of errors is difficult for physicians for several reasons, including guilt and shame, the fear of litigation, concerns about the impact on the physician-patient relationship, and concerns about the impact on their personal reputation. Despite these difficulties, the experience of disclosure of medical error to date has shown that it can strengthen relationships, reduce litigation and the associated costs, and be beneficial to both the patient and physician. Disclosure can be approached in many of the same ways as any other difficult communication situations, with training and preparation helping to improve the process.
The Soave endorectal pullthrough is a commonly performed procedure for the definitive management ... more The Soave endorectal pullthrough is a commonly performed procedure for the definitive management of children with Hirschsprung's disease (HD). Anastomotic stricture is a recognised complication of this procedure . There are multiple causes for these strictures, circular anastomosis being one of them. There are techniques described which alter the shape of the anastomosis of the pulled through bowel to decrease the incidence of strictures. These are oblique [6] and heart-shaped anastomoses. We describe a new technique of oblique anastomosis where the pulled through bowel is anastomosed posteriorly 0.5 cm from the dentate line, and anteriorly 1.5 cm above this point. This oblique anastomosis is designed to lower the stricture rate. If a stricture does occur, an anastomosis near the anocutaneous junction on the posterior aspect also faciltates Y-V anoplasty. We present our experience using this technique. Seventeen consecutive children underwent the procedure at our institution between 2003 and 2006. Only one child developed an anastomotic stricture requiring anal dilatation.
Purpose: The relationship between congenital abdominal wall defects (AWDs) and undescended testes... more Purpose: The relationship between congenital abdominal wall defects (AWDs) and undescended testes (UDTs) is poorly defined. We report a study of infants with AWD and UDT. Methods: Hospital records of newborns with AWD managed during 1998 to 2008 were reviewed. Data analyzed included nature of AWD, position of the testes at birth, final position of the testes, and surgical management. Results: A total of 218 newborns with AWD were identified; 106 (49%) were boys. Of 79 boys with gastroschisis, 26 (33%) had UDT involving 35 testes. Of 27 with exomphalos, 6 (22%) had UDT involving 11 testes. Prolapsed testes were placed in the abdomen at AWD repair, whereas others were observed for "spontaneous" descent. Of 35 UDT in gastroschisis infants, 18 descended spontaneously, and 10 required orchidopexy. Three boys underwent laparoscopy for impalpable testes, 2 underwent orchidectomy, and 1 had bilaterally absent testes. Three cases await orchidopexy. In exomphalos boys with 11 UDTs, 1 gonad descended spontaneously, and 6 had groin exploration (1 absent testis and 5 orchidopexies). Two boys await orchidopexy, and 1 boy (bilateral impalpable testes) was lost to follow-up. Conclusion: Abdominal wall defects are strongly associated with UDT. In boys with gastroschisis, spontaneous descent of the testes may be anticipated in 50% of cases. In those with exomphalos, orchidopexy should be scheduled.
Having reported that 18% of children discontinue use of the antegrade continence enema (ACE) afte... more Having reported that 18% of children discontinue use of the antegrade continence enema (ACE) after 5 years, we aimed to determine long-term use after an ACE procedure. A postal/telephone questionnaire was conducted. Subjects were consecutive children undergoing an ACE between 1993 and 1999. Outcome measures were use of ACE, reasons for nonuse, complications, and overall satisfaction. Of 84 eligible subjects, data were available on 61 (73%) aged 22.4 years (15.5-35.1 years). Underlying diagnoses included spina bifida (n = 27), anorectal malformations (n = 18), constipation (n = 11), Hirschsprung's disease (n = 1), sacral agenesis (n = 2), and trauma/tumor (n = 2). Follow-up was 11.02 years (8.34-14.39 years). Thirty-six (59%) of 61 patients were still using their ACE. Reasons for nonuse were lack of effectiveness (n = 14), complications (n = 5), psychologic issues (n = 2), and poor compliance (n = 2). There was no association between diagnosis and nonuse (chi(2), P = .63). In those still using ACE, the overall satisfaction score was 4.1 (1-5). Several individuals reported feeling abandoned on becoming adults and losing the support they had in childhood. There is a late "failure" rate for the ACE procedure. However, satisfaction was high among those still using the ACE. This study further emphasizes the need for robust transitional care arrangements.
International Journal for Quality in Health Care, 2010
Purpose. Adverse events are increasingly recognized as a source of harm to patients. When such ha... more Purpose. Adverse events are increasingly recognized as a source of harm to patients. When such harm occurs, problems arise in communicating the situation to patients and their families. We reviewed the literature on disclosure across individual and international boundaries, including patients', healthcare professionals' and other stakeholders' perspectives in order to ascertain how the needs of all groups could be better reconciled.
Nasogastric tube insertion is a common clinical procedure carried out by doctors and nurses in NH... more Nasogastric tube insertion is a common clinical procedure carried out by doctors and nurses in NHS hospitals daily. For the last 30 years, there have been reports in the medical literature of deaths and other harm resulting from misplaced nasogastric tubes, most commonly associated with feed entering the pulmonary system. In 2005 the National Patient Safety Agency in England assembled reports of 11 deaths and one incident of serious harm from wrong insertion of nasogastric tubes over a two-year period. The agency issued a safety alert setting out evidence-based practice for checking tube placement. In the two and a half years following this alert the problem persisted with a further five deaths and six instances of serious harm due to nasogastric tube misplacement. This is a potentially preventable error but safety alerts advocating best practice do not appear to reliably reduce risk. Alternative solutions, such as standardising procedures, may be more effective.
Donaldson, Liam J; Rutter, Paul D; Ellis, Benjamin M; Greaves, Felix EC; Mytton, Oliver T; Pebody... more Donaldson, Liam J; Rutter, Paul D; Ellis, Benjamin M; Greaves, Felix EC; Mytton, Oliver T; Pebody, Richard G; Yardley, Iain E.
Objective To establish mortality from pandemic A/H1N1 2009 influenza up to 8 November 2009. Desig... more Objective To establish mortality from pandemic A/H1N1 2009 influenza up to 8 November 2009. Design Investigation of all reported deaths related to pandemic A/H1N1 in England. Setting Mandatory reporting systems established in acute hospitals and primary care. Participants Physicians responsible for the patient. Main outcome measures Numbers of deaths from influenza combined with mid-range estimates of numbers of cases of influenza to calculate age specific case fatality rates. Underlying conditions, time course of illness, and antiviral treatment.
To determine whether recent sexual intercourse might be a cause of microscopic haematuria in pati... more To determine whether recent sexual intercourse might be a cause of microscopic haematuria in patients referred to a urological unit following dipstick detection of urinary haemoglobin. Forty-eight volunteers (24 men and 24 women) consented to have heterosexual intercourse with their regular partner, and to provide samples of urine for testing before and from the first void on the morning after intercourse. After appropriate instruction, volunteers tested their own urine for the presence of blood using standard dipsticks. Any volunteer with haematuria either before or after intercourse was offered a standard haematuria assessment. The results were analysed using the chi-squared test. None of the volunteers tested positively for haematuria immediately before sexual intercourse; six of the 24 women (25%), but no men, became positive after intercourse (P < 0.01). Only one of the six women accepted the offer of a haematuria evaluation and no pathology was identified. These results suggest that up to a quarter of women develop microscopic haematuria as a direct result of sexual intercourse. A history of recent sexual intercourse should therefore be considered when assessing the clinical significance of microscopic haematuria in women.
Medical errors and adverse events are now recognized as major threats to both individual and publ... more Medical errors and adverse events are now recognized as major threats to both individual and public health worldwide. This review provides a broad perspective on major effective, established, or promising strategies to reduce medical errors and harm. Initiatives to improve safety can be conceptualized as a "safety onion" with layers of protection, depending on their degree of remove from the patient. Interventions discussed include those applied at the levels of the patient (patient engagement and disclosure), the caregiver (education, teamwork, and checklists), the local workplace (culture and workplace changes), and the system (information technology and incident reporting systems). Promising interventions include forcing functions, computerized prescriber order entry with decision support, checklists, standardized handoffs and simulation training. Many of the interventions described still lack strong evidence of benefit, but this should not hold back implementation. Rather, it should spur innovation accompanied by evaluation and publication to share the results.
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Papers by Iain Yardley