J Gugenheim, Jf Gravie, A Deleuze, F Borie, M Mathonnet, B Millat. Federation of Visceral and Digestive Surgery
In France, solutions for Patient Safety are established by expert’s consensus under the guidance of the High Authority of Health (HAS) and based on an adverse events database established by HAS in 2006. The database collects informations on adverse events from all surgical specialties and allows analyze of the causes and barriers leading up to adverse events.
This study analysis 614 adverse events involving electrosurgery. Under the direction of the Federation of Visceral and Digestive Surgery (FCVD) the data analysis was performed by a multidisciplinary working group including physicians from 8 different specialties, pharmacists, biomedical engineers and operating room nurses. As a result several key points focussing on prevention, response, and risk mitigation of electrosurgical injuries were established:
These key points describe the different actions to be implemented by each actor in the operating room; control and adjustment of the equipment, patient positioning, safe use of the dispersive and active electrode, team communications, management of patient carrying implantable electronic devices such as a cardiac defibrillator.
The key points specify the actions to be implemented in case of cutaneous or visceral burns and OR fires.
This point describes the recommendations to be implemented regarding:
- The patient: inform, monitor, detect.
- The medical file: patient documentation, description of the incident and recovery measures
- The institutions (hospital, risk management organization, national agency …): report the event, analyze the causes, describe the implementation of corrective actions and measure their effectiveness.
In summary, SPS aims to prevent, recover, and mitigate adverse events related to the use of the electrosurgery. SPS intends to provide professionals in the operating room a safety tool in their daily practice with electrosurgical instruments.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93313
Program Number: P378
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster