دورية أكاديمية
أعرض في EDS

Application of root cause analysis and TEAMSTEPPS post intravesical gas explosion during transurethral resection of the prostate: a rare case report.

التفاصيل البيبلوغرافية
العنوان: Application of root cause analysis and TEAMSTEPPS post intravesical gas explosion during transurethral resection of the prostate: a rare case report.
المؤلفون: Chen IH; Department of Internal Medicine, National Defense Medical Center, Taipei City, Taiwan. treemanhealth@gmail.com.; Institute of Medical Science and Technology, National Sun Yat-sen University, Kaohsiung City, Taiwan. treemanhealth@gmail.com.; Department of Business Management, National Sun Yat-sen University, Kaohsiung City, Taiwan. treemanhealth@gmail.com.; Kaohsiung Armed Forces General Hospital, Kaohsiung City, Taiwan. treemanhealth@gmail.com., Fong CM; Department of Business Management, National Sun Yat-sen University, Kaohsiung City, Taiwan., Chang HS; International Master of Business Administration, National Taichung University of Education, Taichung City, Taiwan., Ni YJ; Department of Urology, Kaohsiung Armed Forces General Hospital, Kaohsiung City, Taiwan., Chiu KN; Institute of Medical Science and Technology, National Sun Yat-sen University, Kaohsiung City, Taiwan., Lee KW; Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung City, Taiwan.
المصدر: BMC urology [BMC Urol] 2024 Jul 04; Vol. 24 (1), pp. 139. Date of Electronic Publication: 2024 Jul 04.
نوع المنشور: Case Reports; Journal Article
اللغة: English
بيانات الدورية: Publisher: BioMed Central Country of Publication: England NLM ID: 100968571 Publication Model: Electronic Cited Medium: Internet ISSN: 1471-2490 (Electronic) Linking ISSN: 14712490 NLM ISO Abbreviation: BMC Urol Subsets: MEDLINE
أسماء مطبوعة: Original Publication: London : BioMed Central, [2001-
مواضيع طبية MeSH: Transurethral Resection of Prostate*/adverse effects , Explosions* , Urinary Bladder*/surgery , Urinary Bladder*/injuries , Root Cause Analysis*, Humans ; Male ; Aged ; Gases ; Patient Care Team ; Intraoperative Complications/etiology
مستخلص: Background: An intravesical gas explosion is a rare complication of transurethral resection of the prostate (TURP). It was first reported in English literature in 1926, and up to 2022 were only forty-one cases. Injury from an intravesical gas explosion, in the most severe cases appearing as extraperitoneal or intraperitoneal bladder rupture needed emergent repair surgery.
Case Presentation: We present a case of a 75-year-old man who suffered an intravesical gas explosion during TURP. The patient underwent an emergent exploratory laparotomy for bladder repair and was transferred to the intensive care unit for further observation and treatment. Under the medical team's care for up to sixty days, the patient recovered smoothly without clinical sequelae.
Conclusions: This case report presents an example of a rare complication of intravesical gas explosion during TURP, utilizing root cause analysis (RCA) to comprehend causal relationships and team strategies and tools to improve performance and patient safety (TeamSTEPPS) method delivers four teamwork skills that can be utilized during surgery and five recommendations to avoid gas explosions during TURP to prevent the recurrence of medical errors. In modern healthcare systems, promoting patient safety is crucial. Once complications appear, RCA and TeamSTEPPS are helpful means to support the healthcare team reflect and improve as a team.
(© 2024. The Author(s).)
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فهرسة مساهمة: Keywords: Intravesical gas explosion; Root cause analysis; Team strategies and tools to enhance performance and patient safety; Transurethral resection of the prostate
المشرفين على المادة: 0 (Gases)
تواريخ الأحداث: Date Created: 20240704 Date Completed: 20240705 Latest Revision: 20240707
رمز التحديث: 20240707
مُعرف محوري في PubMed: PMC11225426
DOI: 10.1186/s12894-024-01520-w
PMID: 38965501
قاعدة البيانات: MEDLINE
الوصف
تدمد:1471-2490
DOI:10.1186/s12894-024-01520-w