Analysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgery

• DOI: 10.1007/s11695-021-05330-z
• Publication Date: 2021-03-05T20:02:21Z
• Authors: Islam Omar; Brijesh Madhok; Chetan Parmar; Omar Khan; Michael Wilson; Kamal Mahawar
• Keywords: Wales; Anticoagulants; Bariatric Surgery; Venous Thromboembolism; Checklist; Obesity, Morbid; 3. Good health; 03 medical and health sciences; 0302 clinical medicine; England; Humans; Patient Safety

Hundreds of thousands of patient-safety clinical incidents are reported to the National Reporting and Learning System (NRLS) database in England and Wales every year. The purpose of this study was to identify bariatric surgery-related learning points from these incidents.We analysed bariatric surgery-related clinical incidents reported to the NRLS database between 01 April 2005 and 31st October 2020. The authors used their experience to identify learning themes, attribute severity, and design a safety checklist from these reported incidents.We identified 541 bariatric surgery-related clinical incidents in 58 different themes. Preoperative, intraoperative, and postoperative incidents represented 30.3% (N = 164), 38.1% (N = 206), and 31.6% (N = 171) incidents respectively. One hundred fifty (27.7%), 244 (45.1%), and 147 (27.2%) incidents were attributed high, medium, and low severity respectively. The most commonly reported high severity theme was the failure of thromboprophylaxis (50; 9.2%). Intraoperative high severity incidents included 17 incidents of stapling of orogastric/nasogastric tubes or temperature probes, 8 missed needles, 8 broken graspers, and 6 incidents of band parts left behind. Postoperatively, the most commonly reported high severity theme was improper management of diabetes mellitus (DM) (35; 6.5%). Medication errors represented a significant proportion of the medium severity incidents.We identified 58 specific themes of bariatric surgery-related clinical incidents. We propose specific recommendations for the prevention of each theme and a safety checklist to help improve the safety of bariatric surgery worldwide.