ArticlePatient safety in surgery2020
Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.
Article in Patient safety in surgery, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. An erratum has been issued. It is linked to trial NCT05286411 (Evaluation of the Implementation of a Quality Improvement Program Through Morbidity and Mortality Reviews in a Developing Country), which is not on this map. Cited by 6 papers.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Evaluation of the Implementation of a Quality Improvement Program Through Morbidity and Mortality Reviews in a Developing Country
Who cites it
6 citing papers in PubMed.
- Development and Evaluation of Clinical Practice Guidelines for Patients Undergoing Hepatectomy.Healthcare (Basel, Switzerland) · 2026Article
- Application of root cause analysis and TEAMSTEPPS post intravesical gas explosion during transurethral resection of the prostate: a rare case report.BMC urology · 2024Article
- Enhancing patient safety: a system-based analysis of morbidity and mortality conferences in managing postoperative bleeding following gastric and pancreatic cancer surgery.BMJ open quality · 2024Review
- Evaluation of the implementation of a quality improvement program through morbidity and mortality reviews in a developing country.Annals of medicine and surgery (2012) · 2022Article
- Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective.BMJ open quality · 2022Article
- Correction to: Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.Patient safety in surgery · 2020Article
Corrections and comments
- Erratum issued
Authors and funding
10 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundThe aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.
methodsThis was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: "Patient", "Tasks", "Individual staff", "Team", "Work environment", and "Management and Institutional context". Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.
resultsIn 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.
conclusionA pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.
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