Risk factors for perfusionist-related near-miss event: A retrospective cohort study in a single center_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIN Tianxiao , CHEN Xing , MENG Weipeng , GUAN Li ,  PENG Qinbao

1. Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, P. R. China;

Corresponding?author：

PENG Qinbao, Email: 214317112@qq.com

Keywords：

Near-miss; perfusionist; cardiopulmonary bypass; adverse events; risk factors

DOI：

10.7507/1007-4848.202208067

Video：

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Objective To explore the risk factors and countermeasures of the perfusionist-related near-miss event (NME) in cardiopulmonary bypass (CPB). Methods The clinical data of the patients who underwent cardiac surgery in the Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University from March 2020 to July 2021 were retrospectively analyzed. According to whether NME occurred during the operation, the patients were divided into an NME group and a non-NME group. The clinical data of the two groups were compared, and the risk factors for NME were analyzed. Results A total of 702 patients were enrolled, including 424 males and 278 females with a median age of 56.0 years. There were 125 patients in the NME group and 577 patients in the non-NME group. The occurrence rate of NME was 17.81%. Univariate analysis showed that there were statistical differences between the two groups in the gender, body surface area, CPB time, European system for cardiac operative risk evaluation score, emergency surgery, type of surgery, night CPB initiation, modified ultrafiltration use, multi-device control, average operation time, et al. (all P<0.05). The above variables were dimensionality reduction processed by least absolute shrinkage and selection operator regression, and the λ of minimum mean square error of 10-fold cross validation was 0.014. The variables of the corresponding model were selected as follows: multi-device control, night CPB initiation, minimum hematocrit, modified ultrafiltration use, CPB time. The results of multivariate logistic regression showed that night CPB initiation [OR=9.658, 95%CI (4.735. 19.701), P<0.01] and CPB time [OR=1.003, 95%CI (1.001, 1.006), P=0.014] were independent risk factors for NME. Conclusion Night CPB initiation and CPB time are independent risk factors for NME during CPB, which should be recognized and early warned in clinical work.

Citation： LIN Tianxiao, CHEN Xing, MENG Weipeng, GUAN Li, PENG Qinbao. Risk factors for perfusionist-related near-miss event: A retrospective cohort study in a single center. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2024, 31(4): 525-530. doi: 10.7507/1007-4848.202208067 Copy

1.	Condello I. Who are you then? I am part of that thing that can do evil and works good: Perfusion. Eur J Cardiothorac Surg, 2022, 62(1): ezac156.
2.	Cammertoni F, Bruno P, Pavone N, et al. Influence of cardiopulmonary bypass set-up and management on clinical outcomes after minimally invasive aortic valve surgery. Perfusion, 2021, 36(7): 679-687.
3.	王偉, 黑飛龍. 體外循環技術的質量控制和標準化. 中華醫學雜志, 2017, 97(38): 2972-2974.
4.	陳瑾, 劉燕, 劉俊琰. 多中心同質化醫療質量管理在體外循環科中的應用. 中國體外循環雜志, 2019, 17(4): 211-214.
5.	胡盛壽. 中國心血管外科的技術發展現狀和醫療質量控制. 手術, 2016, 1(1): 3-7.
6.	中國醫院協會. 中國醫院質量安全管理—第4部分: 醫療管理 (T/CHAS 10-4-6-2018). 北京, 2018.
7.	馮婷婷, 張欣, 譚玲玲, 等. 護理接近失誤管理的研究進展. 中華護理雜志, 2020, 55(1): 153-157.
8.	彭勤寶, 孟維朋, 官莉, 等. 電子體外循環安全核查表的應用與效果分析. 中國體外循環雜志, 2020, 18(6): 355-359.
9.	Spiess BD, Rotruck J, McCarthy H, et al. Human factors analysis of a near-miss event: Oxygen supply failure during cardiopulmonary bypass. J Cardiothorac Vasc Anesth, 2015, 29(1): 204-209.
10.	Belway D, Tran DTT, Rubens FD. Effects of a change in entry-to-practice criteria for cardiovascular perfusion in Canada: Results of a national survey. Perfusion, 2017, 32(4): 296-300.
11.	高永祥, 張晉昕. Logistic回歸分析的樣本量確定. 循證醫學, 2018, 18(2): 122-124.
12.	Puis L, Milojevic M, Boer C, et al. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg, 2020, 30(2): 161-202.
13.	Willcox TW, Baker RA. Incident reporting in perfusion: Current perceptions on PIRS-2. J Extra Corpor Technol, 2020, 52(1): 7-12.
14.	王立偉, 熊紅燕, 易秋月, 等. 2018年至2019年陜西省體外循環不良事件分析. 中國體外循環雜志, 2021, 19(2): 73-77.
15.	Gnoni MG, Saleh JH. Near-miss management systems and observability-in-depth: Handling safety incidents and accident precursors in light of safety principles. Safety Sci, 2017, 91: 154-167.
16.	Wang S, Wang D, Huang X, et al. Risk factors and in-hospital mortality of postoperative hyperlactatemia in patients after acute type A aortic dissection surgery. BMC Cardiovasc Disord, 2021, 21(1): 431.
17.	費忠化, 蔡騰, 蔡國強, 等. 主動脈弓部置換術圍術期大量輸注紅細胞危險因素分析. 心肺血管病雜志, 2022, 41(7): 797-800, 805.
18.	Palanzo DA, Wise RK, Woitas KR, et al. Safety and utility of modified ultrafiltration in pediatric cardiac surgery. Perfusion, 2023, 38(1): 150-155.
19.	Talwar S, Sujith NS, Rajashekar P, et al. Modified ultrafiltration and postoperative course in patients undergoing repair of tetralogy of Fallot. J Card Surg, 2021, 36(10): 3679-3687.
20.	丘俊濤, 張良, 羅新錦, 等. 主動脈夾層手術時機對預后的影響. 中華胸心血管外科雜志, 2018, 34(1): 26-31.
21.	Addis DR, Moore BA, Garner CR, et al. Case start time affects intraoperative transfusion rates in adult cardiac surgery: A single-center retrospective analysis. J Cardiothorac Vasc Anesth, 2020, 34(3): 632-639.
22.	Kenney PS, Nielsen PH, Modrau IS. Daytime-dependent cardioprotection in cardiac surgery: A large propensity-matched cohort study. Ann Thorac Surg, 2020, 110(5): 1629-1636.
23.	中國生物醫學工程學會體外循環分會. 中國體外循環專業技術標準 (2021版). 中國體外循環雜志, 2021, 19(2): 67-72.
24.	Merkle F, Kurtovic D, Starck C, et al. Evaluation of attention, perception, and stress levels of clinical cardiovascular perfusionists during cardiac operations: A pilot study. Perfusion, 2019, 34(7): 544-551.
25.	Dias RD, Riley W, Shann K, et al. A tool to assess nontechnical skills of perfusionists in the cardiac operating room. J Thorac Cardiovasc Surg, 2021, 165(4): 1462-1469.
26.	Lawson C, Predella M, Rowden A, et al. Assessing the culture of safety in cardiovascular perfusion: Attitudes and perceptions. Perfusion, 2017, 32(7): 583-590.
27.	Bauer A, Benk C, Thiele H, et al. Qualification, knowledge, tasks and responsibilities of the clinical perfusionist in Germany. Interact Cardiovasc Thorac Surg, 2020, 30(5): 661-665.
28.	Bouchez S, De Somer F. The evolving role of the modern perfusionist: Insights from transesophageal echocardiography. Perfusion, 2021, 36(3): 222-232.
29.	Seshia SS, Bryan Young G, Makhinson M, et al. Gating the holes in the Swiss cheese (partⅠ): Expanding professor Reason's model for patient safety. J Eval Clin Pract, 2018, 24(1): 187-197.
30.	Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence: Closing the holes. Semin Pediatr Surg, 2015, 24(6): 278-282.
31.	Gierig S, Merkle F, Pawelke C, et al. Simulation in perfusion: Evaluating the efficacy of a specific training with eye-tracking. Perfusion, 2020, 35(8): 717-723.
32.	Merkle F, Kurtovic D, Matschke A, et al. Simulation-based training of critical events during cardiopulmonary bypass: Importance of a critical events checklist. Perfusion, 2021, 36(3): 239-247.
33.	Kulat B. Perfusionist manpower survey. J Extra Corpor Technol, 2019, 51(1): P2-P4.
34.	Joyce DL, Lahr BD, Maltais S, et al. Integration of simulation components enhances team training in cardiac surgery. J Thorac Cardiovasc Surg, 2018, 155(6): 2518-2524.
35.	Kennedy-Metz LR, Wolfe HL, Dias RD, et al. Surgery task load index in cardiac surgery: Measuring cognitive load among teams. Surg Innov, 2020, 27(6): 602-607.
36.	Tomizawa Y, Aoki H, Suzuki S, et al. Eye-tracking analysis of skilled performance in clinical extracorporeal circulation. J Artif Organs, 2012, 15(2): 146-157.
37.	Yamada Y, Nakamura T, Yamada M, et al. Use of augmented reality to assist teaching for future perfusionists in extracorporeal technology. J Extra Corpor Technol, 2019, 51(4): 244-247.
38.	Zenati MA, Leissner KB, Zorca S, et al. First reported use of team cognitive workload for root cause analysis in cardiac surgery. Semin Thorac Cardiovasc Surg, 2019, 31(3): 394-396.

1. Condello I. Who are you then? I am part of that thing that can do evil and works good: Perfusion. Eur J Cardiothorac Surg, 2022, 62(1): ezac156.
2. Cammertoni F, Bruno P, Pavone N, et al. Influence of cardiopulmonary bypass set-up and management on clinical outcomes after minimally invasive aortic valve surgery. Perfusion, 2021, 36(7): 679-687.
3. 王偉, 黑飛龍. 體外循環技術的質量控制和標準化. 中華醫學雜志, 2017, 97(38): 2972-2974.
4. 陳瑾, 劉燕, 劉俊琰. 多中心同質化醫療質量管理在體外循環科中的應用. 中國體外循環雜志, 2019, 17(4): 211-214.
5. 胡盛壽. 中國心血管外科的技術發展現狀和醫療質量控制. 手術, 2016, 1(1): 3-7.
6. 中國醫院協會. 中國醫院質量安全管理—第4部分: 醫療管理 (T/CHAS 10-4-6-2018). 北京, 2018.
7. 馮婷婷, 張欣, 譚玲玲, 等. 護理接近失誤管理的研究進展. 中華護理雜志, 2020, 55(1): 153-157.
8. 彭勤寶, 孟維朋, 官莉, 等. 電子體外循環安全核查表的應用與效果分析. 中國體外循環雜志, 2020, 18(6): 355-359.
9. Spiess BD, Rotruck J, McCarthy H, et al. Human factors analysis of a near-miss event: Oxygen supply failure during cardiopulmonary bypass. J Cardiothorac Vasc Anesth, 2015, 29(1): 204-209.
10. Belway D, Tran DTT, Rubens FD. Effects of a change in entry-to-practice criteria for cardiovascular perfusion in Canada: Results of a national survey. Perfusion, 2017, 32(4): 296-300.
11. 高永祥, 張晉昕. Logistic回歸分析的樣本量確定. 循證醫學, 2018, 18(2): 122-124.
12. Puis L, Milojevic M, Boer C, et al. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg, 2020, 30(2): 161-202.
13. Willcox TW, Baker RA. Incident reporting in perfusion: Current perceptions on PIRS-2. J Extra Corpor Technol, 2020, 52(1): 7-12.
14. 王立偉, 熊紅燕, 易秋月, 等. 2018年至2019年陜西省體外循環不良事件分析. 中國體外循環雜志, 2021, 19(2): 73-77.
15. Gnoni MG, Saleh JH. Near-miss management systems and observability-in-depth: Handling safety incidents and accident precursors in light of safety principles. Safety Sci, 2017, 91: 154-167.
16. Wang S, Wang D, Huang X, et al. Risk factors and in-hospital mortality of postoperative hyperlactatemia in patients after acute type A aortic dissection surgery. BMC Cardiovasc Disord, 2021, 21(1): 431.
17. 費忠化, 蔡騰, 蔡國強, 等. 主動脈弓部置換術圍術期大量輸注紅細胞危險因素分析. 心肺血管病雜志, 2022, 41(7): 797-800, 805.
18. Palanzo DA, Wise RK, Woitas KR, et al. Safety and utility of modified ultrafiltration in pediatric cardiac surgery. Perfusion, 2023, 38(1): 150-155.
19. Talwar S, Sujith NS, Rajashekar P, et al. Modified ultrafiltration and postoperative course in patients undergoing repair of tetralogy of Fallot. J Card Surg, 2021, 36(10): 3679-3687.
20. 丘俊濤, 張良, 羅新錦, 等. 主動脈夾層手術時機對預后的影響. 中華胸心血管外科雜志, 2018, 34(1): 26-31.
21. Addis DR, Moore BA, Garner CR, et al. Case start time affects intraoperative transfusion rates in adult cardiac surgery: A single-center retrospective analysis. J Cardiothorac Vasc Anesth, 2020, 34(3): 632-639.
22. Kenney PS, Nielsen PH, Modrau IS. Daytime-dependent cardioprotection in cardiac surgery: A large propensity-matched cohort study. Ann Thorac Surg, 2020, 110(5): 1629-1636.
23. 中國生物醫學工程學會體外循環分會. 中國體外循環專業技術標準 (2021版). 中國體外循環雜志, 2021, 19(2): 67-72.
24. Merkle F, Kurtovic D, Starck C, et al. Evaluation of attention, perception, and stress levels of clinical cardiovascular perfusionists during cardiac operations: A pilot study. Perfusion, 2019, 34(7): 544-551.
25. Dias RD, Riley W, Shann K, et al. A tool to assess nontechnical skills of perfusionists in the cardiac operating room. J Thorac Cardiovasc Surg, 2021, 165(4): 1462-1469.
26. Lawson C, Predella M, Rowden A, et al. Assessing the culture of safety in cardiovascular perfusion: Attitudes and perceptions. Perfusion, 2017, 32(7): 583-590.
27. Bauer A, Benk C, Thiele H, et al. Qualification, knowledge, tasks and responsibilities of the clinical perfusionist in Germany. Interact Cardiovasc Thorac Surg, 2020, 30(5): 661-665.
28. Bouchez S, De Somer F. The evolving role of the modern perfusionist: Insights from transesophageal echocardiography. Perfusion, 2021, 36(3): 222-232.
29. Seshia SS, Bryan Young G, Makhinson M, et al. Gating the holes in the Swiss cheese (partⅠ): Expanding professor Reason's model for patient safety. J Eval Clin Pract, 2018, 24(1): 187-197.
30. Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence: Closing the holes. Semin Pediatr Surg, 2015, 24(6): 278-282.
31. Gierig S, Merkle F, Pawelke C, et al. Simulation in perfusion: Evaluating the efficacy of a specific training with eye-tracking. Perfusion, 2020, 35(8): 717-723.
32. Merkle F, Kurtovic D, Matschke A, et al. Simulation-based training of critical events during cardiopulmonary bypass: Importance of a critical events checklist. Perfusion, 2021, 36(3): 239-247.
33. Kulat B. Perfusionist manpower survey. J Extra Corpor Technol, 2019, 51(1): P2-P4.
34. Joyce DL, Lahr BD, Maltais S, et al. Integration of simulation components enhances team training in cardiac surgery. J Thorac Cardiovasc Surg, 2018, 155(6): 2518-2524.
35. Kennedy-Metz LR, Wolfe HL, Dias RD, et al. Surgery task load index in cardiac surgery: Measuring cognitive load among teams. Surg Innov, 2020, 27(6): 602-607.
36. Tomizawa Y, Aoki H, Suzuki S, et al. Eye-tracking analysis of skilled performance in clinical extracorporeal circulation. J Artif Organs, 2012, 15(2): 146-157.
37. Yamada Y, Nakamura T, Yamada M, et al. Use of augmented reality to assist teaching for future perfusionists in extracorporeal technology. J Extra Corpor Technol, 2019, 51(4): 244-247.
38. Zenati MA, Leissner KB, Zorca S, et al. First reported use of team cognitive workload for root cause analysis in cardiac surgery. Semin Thorac Cardiovasc Surg, 2019, 31(3): 394-396.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Risk factors for perfusionist-related near-miss event: A retrospective cohort study in a single center

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