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Table 1 3D analysis of some example incidents in emergency general surgery

From: A three-dimensional model of error and safety in surgical health care microsystems. Rationale, development and initial testing

Case Description of Problem Analysis of Contributory Factors Classification Commentary
1 Long term Crohn's disease: Emergency stricture resection for obstruction. ARDS postoperatively Overhydration, no antibiotics: 2y to deficient protocols, supervision, training. Culture +System failures Culture accepted system where undertrained juniors did their best without adequate supervision - as no alternative appeared possible.
2 91 yr old with apparently strangulated hernia, but negative exploration, followed by MI Inappropriately rapid decision to operate without investigation Culture failure Radiology and senior consultation available, but not accessed due to "macho" culture. Trainee's perception of their role emphasised self- reliance and decisiveness, and characterised use of expensive investigations and discussion with seniors as indicators of lack of experience and competence
3 Possible intestinal obstruction; significant arm soft tissue injury from CT contrast extravasation Lack of protocol and experience, plus equipment which hinders immediate detection and cessation of injection Culture, System and Technology failure System could have been devised to defend against obvious risks of technology but culture did not demand it. More detailed and explicit protocol incorporating checks of intravenous access quality before and during infusion needed: however culture resistant to close adherence to standardised protocols, which is regarded as interfering with professional freedom
4 Second laparotomy for ileus after initial division of adhesions Overhydration, late withdrawal of epidural: 2y to lack of protocols System + Culture failures Lack of protocols, Failure of culture to insist on closer surveillance. Inadequate handover of information at shift changes. Excessive workload at times, putting pressure on junior doctors' memory and stamina.
5 Schizophrenic with missed caecal volvulus; anastomotic leak, 2nd laparotomy, ITU Failure to perform appropriately timely investigations or postop surveillance in difficult patient Culture failure System malfunctioned due to cultural acceptance of suboptimal care for "difficult" patients. Blood tests and observations omitted to avoid challenging situations
6 Pneumonia and resp. failure after long laparotomy Inadequate analgesia from failed epidural, then oversedation from incorrectly prescribed PCA System & Technology failures Inadequate access to prompt expert pain management; PCA pump easy to misuse. No clear detailed protocol for epidural or PCA care. De-skilling of junior medical and nursing staff by reliance on specialist pain team who were not always promptly available. Juniors reluctant either to make decision to change analgesic strategy or to ask for senior guidance.