General surgical adverse events in a UK district general hospital-lessons to learn.

BACKGROUND: An adverse event (AE) is defined as an unintended injury or complication caused by healthcare management rather than the disease process that may prolong admission and lead to disability or death. This study retrospectively assessed all reported general surgery-related AEs in a district general hospital in the south-east of England. METHODS: All general surgical AEs arising from adult inpatient admissions between 2002 and 2007, that had been reported to the risk management team, following completion of the standard 'Adverse Incident Report Form', were retrospectively reviewed. RESULTS: There were 24,185 general surgical admissions over the period of the study; 461 AEs were reported (1.9% mean annual incident rate; 95% CI, 1.3%-2.5%). The majority (85%) were near miss or no injury events (category I and II) while serious/serious near-miss incidents accounted for just 2% of events. Communicative or administrative problems were implicated in 54% of cases while 12% arose from theatre/surgery-related failure. Of 58 medico-legal claims (0.24% of admissions) that were made, 16 (27.5%) progressed to the law courts for formal settlement. CONCLUSION: The reported annual AE incident rate of approximately 2% is well below the national average: this may be due to pre-selection of general surgery-related AEs or represent under-reporting of incidents. The vast majority of AEs were related to administrative and communicative error. These areas must be addressed if patient safety and outcome is to be significantly improved.

Outpatient general surgical follow-up: are we using this resource effectively?

BACKGROUND: Raised patient expectations and the 2-week rule for the investigation of suspected malignancy have led to heightened demands on surgical outpatient clinics. In this context, the utility of benign post-operative or investigative follow-ups requires justification. METHODS: The surgical outpatient clinic workload of four substantive general surgeons at a typical DGH was analysed over a 4-week period. All notes were examined to identify referral source, management plan and whether that clinic attendance was justified. RESULTS: Twenty three clinics (410 patients) were examined over the period of this study. Three hundred and twenty one patient episodes were examined; 52 episodes did not occur due to patient non-attendance and 37 episodes were not accounted for ('missing/incomplete data'). Thirty three percent of the patients underwent consultant review whilst 57% were reviewed by middle grade surgeons and 9% by SHO/ST2 doctors. Forty eight percent of the consultations were new referrals: 37% of these patients were added to the elective surgical waiting list. One hundred and sixty eight follow-up consultations occurred, which included cancer patients (6%), review patients (12%), patients attending for investigative results (13%) and benign post-operative follow-ups (22%). Forty six of the 69 (66%) post-operative follow-ups were deemed unnecessary as patients were being seen after benign procedures (hernia repair, anorectal surgery or laparoscopic cholecystectomy). CONCLUSION: Over 50% attendances (21/41) for 'normal' results could have been avoided by the use of a directed informative letter. Outpatient clinics are an important resource whose usage must be optimised.

Mycotic aneurysm of the posterior tibial artery -- a rare complication of bacterial endocarditis: a case report.

INTRODUCTION: Distal arterial embolisation and subsequent aneurysm formation are rare occurrences and most are secondary to trauma. We have found no case reports that describe posterior tibial aneurysm formation secondary to bacterial endocarditis. CASE PRESENTATION: We report the case of a 47-year-old Caucasian man who, 2 years after an episode of subacute bacterial endocarditis, presented with signs and symptoms consistent with posterior tibial aneurysm formation. CONCLUSION: Posterior tibial aneurysm formation is a rare occurrence, most commonly occurring after trauma and, although other causes have been described, to our knowledge, endocarditis has not been implicated before, and as such should therefore be borne in mind when dealing with cases where no obvious aetiology is evident.

Indwelling trans-anastomotic rectal tubes in colorectal surgery: a survey of usage in UK and Ireland.

BACKGROUND: The use of rectal tubes in colorectal surgery appears to be a matter of individual choice, with little documented evidence to support their use. This study assesses the current practice of rectal tubes amongst consultant members of the Association of Coloproctology of Great Britain & Ireland (ACPGBI). METHODS: A piloted questionnaire was sent to practising ACPGBI consultant members listed in the 2003-04 directory. Statistical analysis was performed using SPSS software and Fishers exact test. RESULTS: Three hundred and thirty-nine replies were received from 579 posted questionnaires (response rate = 58.5%). Rectal tubes were used by 116 (35%) of responding surgeons. Rectal tubes were more commonly used by surgeons with less than 10 years practice as a consultant (P < 0.005). The main indications for tube placement were following ileo-anal or colonic pouch surgery (73%), after any anterior resection (36%) (rectal tubes were reserved for only low anterior resections by 16% of surgeons) and in the rectal stump after total or subtotal colectomy for acute colitis (11%). Twenty-three percent of these practising surgeons would use a rectal tube as an alternative to a diverting stoma, predominantly in selected patients following ileo-anal pouch surgery. A Foley catheter was the commonest type of tube used (70%) and this was usually placed above the anastomosis (80%). Rectal tubes were left in situ for a median of 5 days (range = 1-13 days). Three surgeons (2.6%) reported serious complications including tube perforation of the bowel or anastomosis. Several different mechanisms were suggested for the purpose and functioning of the rectal tube, the commonest being to decompress the rectum and/or pouch. CONCLUSION: Rectal tube placement is simple and safe and is used by a third of colorectal surgeons in UK and Ireland. Given their simplicity, the efficacy of rectal tubes in reducing local anastomotic complications requires further evaluation within the confines of a randomised controlled trial.