A systems approach to identifying patient safety problems in arterial surgery

Abstract

In the face of the oft-quoted dictum ‘primum non nocere’, it is now widely recognised that a significant number of patients come to harm whilst in hospital. A large body of evidence demonstrates that half of all harm events are preventable and the operating theatre appears to be the most common site for adverse events to occur. For patients undergoing arterial intervention, technical expertise and risk-factor management are clearly important in achieving excellent outcomes. Recent research in vascular surgery has focussed on volume-outcome relationships and the impact of advancements in endovascular intervention. By contrast, there is a relative lack of research examining the extraordinarily complex system within which patients with arterial disease are treated. This thesis aims to develop a broad understanding of system failures and their relationship with patient safety and outcomes in arterial surgery in the British NHS. In section I (chapter 1 and 2) the systems approach is outlined and discussed and the rationale for adopting this approach in arterial surgery is provided. Section II consists of three exploratory studies: chapter 3 presents a systematic review of the literature examining the impact of system factors on safety in arterial surgery; chapter 4 reports a mixed-methods study exploring surgeons’ perceptions of the causes of adverse events in arterial surgery; and chapter 5 presents a multi-centre study of safety culture in vascular operating departments in England. Section III provides an account of the LEAP study: a multi-centre study of system failures occurring during aortic intervention. The methods and main findings of the LEAP study are presented in chapters 6 and 7. Chapter 8 reports on the determinants of intraoperative system failures and the relationship between intraoperative failure and patient outcome. Chapter 9 summarises the main findings and limitations of this thesis, and discusses recommendations for practice and future research.