International Centre for Surgical Safety, Keenan Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada.
Department of Surgery, University of Toronto, Toronto, ON, Canada.
Ann Surg. 2020 Jan;271(1):122-127. doi: 10.1097/SLA.0000000000002863.
To characterize intraoperative errors, events, and distractions, and measure technical skills of surgeons in minimally invasive surgery practice.
Adverse events in the operating room (OR) are common contributors of morbidity and mortality in surgical patients. Adverse events often occur due to deviations in performance and environmental factors. Although comprehensive intraoperative data analysis and transparent disclosure have been advocated to better understand how to improve surgical safety, they have rarely been done.
We conducted a prospective cohort study in 132 consecutive patients undergoing elective laparoscopic general surgery at an academic hospital during the first year after the definite implementation of a multiport data capture system called the OR Black Box to identify intraoperative errors, events, and distractions. Expert analysts characterized intraoperative distractions, errors, and events, and measured trainee involvement as main operator. Technical skills were compared, crude and risk-adjusted, among the attending surgeon and trainees.
Auditory distractions occurred a median of 138 times per case [interquartile range (IQR) 96-190]. At least 1 cognitive distraction appeared in 84 cases (64%). Medians of 20 errors (IQR 14-36) and 8 events (IQR 4-12) were identified per case. Both errors and events occurred often in dissection and reconstruction phases of operation. Technical skills of residents were lower than those of the attending surgeon (P = 0.015).
During elective laparoscopic operations, frequent intraoperative errors and events, variation in surgeons' technical skills, and a high amount of environmental distractions were identified using the OR Black Box.
描述微创手术实践中的术中错误、事件和干扰，并测量外科医生的技术技能。
手术室（OR）中的不良事件是外科患者发病率和死亡率的常见原因。不良事件通常是由于操作和环境因素的偏差引起的。尽管全面的术中数据分析和透明披露已被提倡用于更好地了解如何提高手术安全性，但很少这样做。
我们在一家学术医院进行了一项前瞻性队列研究，在该医院实施名为 OR 黑盒的多端口数据采集系统后的第一年，对 132 例接受择期腹腔镜普外科手术的连续患者进行了研究，以识别术中错误、事件和干扰。专家分析员对术中干扰、错误和事件进行了特征描述，并将学员作为主要操作者参与度进行了测量。对主治医生和学员的技术技能进行了比较，包括原始数据和风险调整数据。
听觉干扰中位数为每例 138 次[四分位距（IQR）96-190]。84 例（64%）至少出现 1 次认知干扰。每例错误中位数为 20 次（IQR 14-36），事件中位数为 8 次（IQR 4-12）。错误和事件在手术的解剖和重建阶段经常发生。住院医师的技术技能低于主治医生（P=0.015）。
使用 OR 黑盒，在择期腹腔镜手术中，识别出频繁的术中错误和事件、外科医生技术技能的差异以及大量的环境干扰。
