Prospective assessment of intraoperative precursor events during cardiac surgery.

OBJECTIVE: Increasing attention has been afforded to the ubiquity of medical error and associated adverse events in medicine. There remains little data on the frequency and nature of precursor events in cardiac surgery, and we sought to characterize this. METHODS: Detailed, anonymous information regarding intraoperative precursor events (which may result in adverse events) was collected prospectively from six key members of the operating team during 464 major adult cardiac surgical cases at three hospitals and were analyzed with univariable statistical methods. RESULTS: During 464 cardiac surgical procedures, 1627 reports of problematic precursor events were collected for an average of 3.5 and maximum of 26 per procedure. 73.3% of cases had at least one recorded event. One-third (33.3%) of events occurred prior to the first incision, and 31.2% of events occurred while on bypass. While 68.0% of events were regarded as minor in severity (e.g., delays and missing equipment), a substantial proportion (32.0%) was considered major and included anastomotic problems, pump failure, and drug errors. Most problems (90.4%) were reported as being compensated for, although many (30.9%) were never discussed among the team. Major events were more likely to be discussed (p<0.0001) and less likely to have been previously encountered (p=0.0005). Perceptions of the severity and compensation of events varied across the team, as did temporal patterns of reporting (p<0.0001). CONCLUSIONS: A wide range of problematic precursor events occurs during the majority of cardiac surgery procedures. Attention to causes and ways of preventing these precursor events could have an impact on the rate of significant errors and improve the safety of cardiac surgery.     

Sources of preventable errors related to transfusion

BACKGROUND AND OBJECTIVES: Transfusion errors always remain under-reported owing to a lack of awareness about transfusion-related adverse events among the hospital staff and an inadequate feedback system in most of the transfusion centres. This article reports the results obtained from a study carried out to investigate the sources and types of errors in our tertiary care hospital. MATERIALS AND METHODS: The errors reported by the blood bank staff (i.e. reception counter clerical and technical staff) and the residents in charge of the patient, were studied over a period of 1 year (from May 1998 to April 1999) and classified based on the site of occurrence. RESULTS: A total of 123 errors were detected over the 1-year study period. Of these 123 errors, 107 (86.99%) occurred outside the blood bank and 16 (13%) in the blood bank. CONCLUSION: Errors occur most frequently outside the blood bank, and the bedside of the patient is the main location.     

Development and description of New Nordic Diet scores across infancy and childhood in the Norwegian Mother,Father and Child Cohort Study (MoBa)

In recent years, examining dietary patterns has become a more common way of investigating potential associations between diet and adverse health outcomes. The New Nordic Diet (NND) is a potentially healthy and sustainable dietary pattern characterized by foods that are locally available and traditionally consumed in the Nordic countries. The diet has been typically examined in adult populations, and less is known about compliance to the NND from infancy throughout childhood. In the current study, we therefore aimed to develop and describe child age‐specific NND scores. This study is based on the Norwegian Mother, Father and Child Cohort Study (MoBa) and uses data from the Medical Birth Registry of Norway (MBRN). We have previously developed a NND score for the maternal diet during pregnancy, and the development of the child diet scores was based on the rationale of this score. Food frequency data from n = 89 715 at child age 6 months, n = 76 432 at 18 months, n = 58 884 at 3 years, and n = 35 978 at 7 years were used to construct subscales in accordance with the maternal diet score. Subscales were composed of responses to a selection of food and drink items or other questions and were dichotomized by the median, yielding four age‐specific diet scores where the possible scoring ranged from 0 to 6 at 6 months and 3 years and from 0 to 9 at 18 months and 7 years. The developed scores will be used to examine associations with childhood overweight and cognitive and mental development in future studies.     

Severe stenosis of bioprosthetic valve due to late valve thrombosis

The typical cause of bioprosthetic valve dysfunction over years is calcification of leaflets, pannus formation, or tears due to structural degeneration. Thrombosis is rare as the valves get endothelialized early on, and, hence, anticoagulation is not recommended beyond 6 months after valve replacement. While bioprosthetic valve thrombosis is unusual (0.03% to 0.34%/year), it can be associated with significant mortality and morbidity. Here, we present a case of a middle-aged man with history of bioprosthetic mitral valve who presented with syncopal episode and was referred to us for mitral valve replacement for tentative bioprosthetic valve degeneration and stenosis. However, preoperative work up revealed prosthetic valve thrombosis which was successfully treated with anticoagulation.