Houssaini Kholoud, Lahnaoui Oumayma, Souadka Amine, Majbar Mohamed-Anass, Ghanam Abdelilah, El Ahmadi Brahim, Belkhadir Zakaria, Amrani Leila, Mohsine Raouf, Benkabbou Amine
Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.
Intensive Care Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco.
Patient Saf Surg. 2020 Sep 29;14:36. doi: 10.1186/s13037-020-00261-7. eCollection 2020.
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.
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.
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.
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.
汇总根本原因分析（AggRCA）旨在增进对导致患者伤害（包括手术并发症）的系统漏洞的理解。由于方法复杂和资源限制，其应用仍然较少。本研究旨在使用AggRCA确定肝切除术后严重并发症的主要模式。
这是一项回顾性定性研究，旨在确定导致严重并发症的主要模式，严重并发症定义为肝切除术后90天内根据Clavien-Dindo分类严格高于IIIa级。从电子数据库中识别出2018年1月1日至2019年12月31日期间发生的所有连续性严重并发症，并纳入AggRCA。这包括一个基于50个促成因素的结构化发病率和死亡率审查（MMR）报告工具，这些因素改编自6个ALARM类别：“患者”、“任务”、“个体工作人员”、“团队”、“工作环境”以及“管理和机构背景”。对单病例个体参与者根本原因分析（RCA）得出的数据进行集体验证，然后汇总。主要模式由超过半数病例报告的促成因素提出。
在105例连续性肝切除病例中，15例患者（14.3%）发生了严重术后并发症，其中5例（4.8%）死亡。AggRCA识别出36个促成因素。超过半数病例报告了8个促成因素，并归纳为三种相互交织的模式：（1）围手术期过程中断，（2）术中意外变更，（3）沟通无效。
一个实用的汇总RCA过程基于对有限数量事件的分析和合理的资源投入，增进了我们对系统漏洞的理解。对导致严重并发症的模式的识别为未来超出肝切除范围的情境化安全干预奠定了基础。
