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

Abstract

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.

Beware of lethal Wernicke's encephalopathy after cytoreductive surgery with HIPEC for peritoneal pseudomyxoma: Case report of morbidity and mortality review

“…This unusual complication was discussed in our weekly morbidity and mortality review (MMR). We used a root cause analysis [10] based on the ALARM framework [11] transcripted to an Ishikawa diagram, to identify the contributing factors resulting in this complication.…”

“…We have established in our department a weekly procedure of MMR to examine all cases of severe complications occurring within 90 postoperative day [9] . A root cause analysis [10] is performed based on the ALARM framework from the French High Authority of Health (HAS) [11] , to analyze contributing factors and suggest measures of improvement in order to prevent or detect this lethal situation.…”

Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective

“…16 30 A second shortcoming of current SAE investigations is that hospitals typically focus on single events within their own organisation, 13 14 even though attempts to learn from aggregate analysis of multiple events across hospitals, as already performed in Australia 37 and the USA, 38 39 are believed to improve learning. [38][39][40][41] It helps to discover combinations of recurring, underlying, patterns of causes and contributing factors 42 and may improve the formulation of more effective, system-aimed recommendations. 14 38 However, methods for analysing SAEs vary substantially, 10 which complicates aggregate crosshospitals analysis of SAEs.…”