Authors: Hiroshi Yasuhara Kazuhiko Fukatsu Takami Komatsu Satoshi Murakoshi Yuhei Saito Yushi Uetera
Publish Date: 2014/06/21
Volume: 38, Issue: 11, Pages: 3015-3022
Abstract
The influence of broken sophisticated surgical instruments on the safety of surgery has yet to be determined in spite of an assumption that breakage of surgical instruments is not associated with critical incidents The purpose of the present study was to delineate the risk from breakage of surgical instruments used in surgery assisted by endoscopyA retrospective analysis was conducted to determine the frequency of breakage of instruments used in 39817 operations from 2007 to 2011 Data of breakage were collected using incident/nearincident reports and the request forms for repair of broken instrumentsDuring the study period 441 instruments were reported to be broken intraoperatively and 7541 were found to be broken on inspection The incidence of breakage adjusted by the number of operations and the number of uses suggested that instruments for endoscopyassisted surgery are broken more frequently intraoperatively than are any other type of instruments visceral surgery 0039 versus 0017 P = 00002 RR = 2318 obstetrics/gynecology 0023 versus 00067 P 00001 RR = 3461 thoracic surgery 0019 versus 0004 P = 00772 RR = 5212 Inappropriate use and wearing out were two major possible causes of breakage of instruments The predominant adverse events were suggested to be attributable to parts falling off broken instruments because of inappropriate useOur results demonstrated that surgery assisted by endoscopy has its own occult risk which has not been previously highlighted Minimally invasive surgery is not necessarily safe with respect to breakage of surgical instruments Our data provide substantial evidence for higher risk of instrument breakage in endoscopyassisted surgery as well as its possible detrimental effect on patient safety
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