Enhancing patient safety: a system-based analysis of morbidity and mortality conferences in managing postoperative bleeding following gastric and pancreatic cancer surgery.

Morbidity and mortality conferences (MMCs) have evolved beyond their traditional educational role to become instrumental in enhancing patient safety. System-based MMCs offer a unique perspective on patient safety by dissecting systemic factors contributing to adverse events. This paper reviews the impact of MMC in managing postoperative bleeding after gastric and pancreatic cancer surgery, within the constraints of limited resources. The study conducted at the National Institute of Oncology in Rabat, Morocco, analysed 18 MMC of haemorrhage following gastric and pancreatic surgeries and allowed to identify two patterns of cumulative factors contributing to adverse events. The first one relates to organisational issues and the second to postoperative management. Fifteen recommendations of improvement emerged from MMC addressing elements of these patterns with an implementation rate of 53.3%.

The learning curve of laparoscopic rectal cancer surgery of millennial surgeons: Lessons for a safe implementation in low- and middle-income countries.

Objective: This study aimed to analyse the learning curve (LC) in laparoscopic rectal cancer resections of 2 millennial surgeons during the implementation of the first laparoscopic rectal cancer surgery programme in low- and middle-income country (LMIC) cancer centre. Methods: All consecutive patients operated by two millennial surgeons for primary rectal adenocarcinoma between January 2018 and March 2020 were included. The LC was analysed for operative duration and conversion to open surgery using both cumulative sum (CUSUM) and/or variable life-adjusted display (VLAD) charts. Results: Eighty-four patients were included, 45 (53.6%) men with a mean age of 57.3 years. Abdominoperineal resection was performed in 31 (36.9%) cases and resections were extended to other organs in 20 (23.8%) patients. Thirteen patients (15.5%) had conversion to open surgery. Using CUSUM, Learning curve based on conversion was completed at 12 cases for the first surgeon versus 10 cases for the second. While using VLAD and learning curve-CUSUM (LC-CUSUM), the cases needed were 26 vs 24 respectively. The median operative duration was 314 min with a LC completed at cases (17 vs. 26), and (18 vs. 29) using, respectively, standard and LC-CUSUM. Conclusions: This study shows a safe and short LC of millennial surgeons during the implementation of a laparoscopic rectal cancer surgery in an LMIC cancer centre, and the valuable use of modern statistical methods in the prospective assessment of LC safety during surgical training.

Evaluation of the implementation of a quality improvement program through morbidity and mortality reviews in a developing country.

Background: Morbidity and mortality reviews represent an opportunity to discuss adverse events and healthcare issues. Aim: Report the first experience of implementing a procedure of MMR, and assess its impact on quality improvement. Methods: From July 2019 to December 2019, members of the surgical and ICU departments designed and implemented a regular procedure of MMR. Cases of severe postoperative complications after curative resection for digestive cancer were selected to be presented by a surgical resident and discussed in an interdisciplinary conference following a standardized presentation based on an analysis tool adapted from the ALARM framework. Process was assessed by the number of MMRs held, number and type of recommendations issued and implemented. Results: Among 13 serious complications during the study period, 10 were discussed. The "Tasks" category was activated in 90% of the cases where lack or misuse of protocols was identified in 90% of the events discussed. Test results availability or accuracy were incarnated in 30% of cases. Poor communication was a contributing factor in 60% of the cases. Written medical records were defective in 40% of the cases. From 16 recommendations for improvement emitted, 87.5% (14/16) were translated into projects and successfully implemented. Conclusions: a standardized and regular procedure of morbidity and mortality reviews in a tertiary care facility in a developing country allowed a significant improvement in patient care through quality initiatives implementation. MMRs might be a strong tool for the improvement of surgical care particularly for low-mid income countries.

Mid-Term Audit of a National Peritoneal Surface Malignancy Program Implementation in a Low Middle Income Country: The Moroccan Experience.

Implementing a multimodal management of peritoneal surface malignancies is a steep and complex process, especially as complete cytoreductive surgery (CRS) is the backbone and the major prognostic factor for hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. The implementation of such a program is a challenging process, particularly in low-middle income (LMIC) countries where ressource restrictions may represent a major hurdle to HIPEC appliances acquisition. Herein is the first audit of the implementation of a national peritoneal malignancy program in a north African country. The audit process was performed according to the three implementation steps, namely initiation ("1":2005-2008), transition ("2":2009-2013) and consolidation ("3":2014-2017). We included all consecutive CRS without HIPEC performed with curative intent for ovarian, gastric, colorectal and pseudomyxoma peritonei type of malignancies with an Eastern Cooperative Oncology Group (ECOG) performance Status ≤ 2. Target outcomes for incomplete cytoreduction (ICRS), serious complications ≥ 3b according to the Clavien-Dindo scoring, and early oncologic failure (EOF; disease progression within 2 years of treatment) were compared between the three phases. Independent risk factors correlated to these three outcomes were calculated using a logistic regression model.198 CRS procedures were completed with 49, 60 and 89 cases performed in the three phases, respectively. Overall, patients were comparable except for ECOG and ASA scores which were more severe in the third phase. The comparison of ICRS, serious complications and EOF rates showed a significant reduction between the three phases with (34%, 18% and 4% p = <0.001), (30.6%, 20% and 11.2%, p = 0.019) and (38.8%, 23.3% and 12.4% p = 0.002) respectively. Undergoing CRS in phase 3 on the other hand was a predictive factor of better short term surgical and oncological outcomes and completeness of cytoreduction, while ECOG performance status and spleno-pancreatectomy were also predictive factors of serious complications.

Correction to: Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.

An amendment to this paper has been published and can be accessed via the original article.

Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.

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.

Assessment of the Nature and Severity of Pain Using SF-MPQ for Cancer Patients at the National Institute of Oncology in Rabat in 2015.

BACKGROUND: Cancer is a worldwide health problem and pain is among the most common and unpleasant effects affecting well-being of cancer patients. Accurate description of pain can help physicians to improve its management. Many English tools have been developed to assess pain. Only a limited number of these are applied in Arab countries. Our aim was to assess the quality, the nature and the severity of pain using the short McGill Pain Questionnaire (SF-MPQ) on cancer patients in the National Institute of Oncology (NIO) in Rabat, Morocco. MATERIALS AND METHODS: The tool used was the SF-MPQ inspired from the Arabic version of the MPQ. The subjects were cancer patients (N=182) attending the NIO, from 24th October 2015 to 8th January 2016, ≥18 years old, experiencing pain and coming to have or to update their pain medication. RESULTS: The rate of participation was 96.3%. Eight patients haddif culties to express their pain using descriptors, but could use the Visual Analogue Scale (VAS) and the body diagram. The most frequent sensory descriptors were 'Throbbing', 'Shooting', 'Hot-Burning'. The most used affective descriptor was 'Tiring-Exhausting'. The mean VAS was 6.6 (2.4). The mean score of all items was 11.9 (7.8). The patients were suffering from severe pain. The internal consistency of the form was acceptable. CONCLUSIONS: The findings indicate that most of the patients attending the pain center of the NIO could use the descriptors of the SF-MPQ to describe their pain. They indicate the usefulness of the SF-MPQ to assess the nature and the severity of pain in cancer patients. This tool should now be tested in other Moroccan and Arabic contexts associated with other tools in clinical trials.