Serious incidents in testicular torsion management in England, 2007-2019: Optimising individual and training factors are the key to improved outcomes
BAUS ePoster online library. Menzies-wilson R. 06/21/21; 319121; p8-3
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Richard Menzies-wilson
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Abstract
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Objectives: To establish the healthcare factors that contribute to testicular torsion adverse events (orchidectomies) and near misses.
Materials and Methods: This was a retrospective record review and analysis. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12 year period to the Strategic Executive Information System' (StEIS) database. The Protocol was used to theme the contributing factors linked to adverse events (orchidectomies) and near-misses.
Results: Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were 'near misses'. Factors contributing to all incidents were: Individual staff/Training (38%); Team (18%); Work Environment (16%); Task & technology (14%); Institutional Context (13%). Subgroup analysis of incidents resulting in orchidectomies showed that 88% were due to individual/training factors.
Conclusion: This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near miss incidents in patients presenting with testicular torsion. In England there are a significant number of orchidectomies occurring annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and more exposure of trainees and medical students to urology to improve testicular salvage rate.
Materials and Methods: This was a retrospective record review and analysis. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12 year period to the Strategic Executive Information System' (StEIS) database. The Protocol was used to theme the contributing factors linked to adverse events (orchidectomies) and near-misses.
Results: Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were 'near misses'. Factors contributing to all incidents were: Individual staff/Training (38%); Team (18%); Work Environment (16%); Task & technology (14%); Institutional Context (13%). Subgroup analysis of incidents resulting in orchidectomies showed that 88% were due to individual/training factors.
Conclusion: This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near miss incidents in patients presenting with testicular torsion. In England there are a significant number of orchidectomies occurring annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and more exposure of trainees and medical students to urology to improve testicular salvage rate.
Objectives: To establish the healthcare factors that contribute to testicular torsion adverse events (orchidectomies) and near misses.
Materials and Methods: This was a retrospective record review and analysis. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12 year period to the Strategic Executive Information System' (StEIS) database. The Protocol was used to theme the contributing factors linked to adverse events (orchidectomies) and near-misses.
Results: Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were 'near misses'. Factors contributing to all incidents were: Individual staff/Training (38%); Team (18%); Work Environment (16%); Task & technology (14%); Institutional Context (13%). Subgroup analysis of incidents resulting in orchidectomies showed that 88% were due to individual/training factors.
Conclusion: This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near miss incidents in patients presenting with testicular torsion. In England there are a significant number of orchidectomies occurring annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and more exposure of trainees and medical students to urology to improve testicular salvage rate.
Materials and Methods: This was a retrospective record review and analysis. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12 year period to the Strategic Executive Information System' (StEIS) database. The Protocol was used to theme the contributing factors linked to adverse events (orchidectomies) and near-misses.
Results: Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were 'near misses'. Factors contributing to all incidents were: Individual staff/Training (38%); Team (18%); Work Environment (16%); Task & technology (14%); Institutional Context (13%). Subgroup analysis of incidents resulting in orchidectomies showed that 88% were due to individual/training factors.
Conclusion: This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near miss incidents in patients presenting with testicular torsion. In England there are a significant number of orchidectomies occurring annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and more exposure of trainees and medical students to urology to improve testicular salvage rate.
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