Post-Procedure Complications Monitoring Programme 46th Review Meeting Friday, 17 October 2014 4:00 - 6:00pm, 4/F, Arthur K C Li Surgical Library Lui Che Woo Clinical Sciences Building, PWH
Attendance Present Prof. Paul B S Lai (Chairman) Team 1 – Dr. Sunny Y S Cheung & Dr. Ray K W Hung Team 2 – Dr. Yip Hon Chi & Dr. Shirley Y W Liu Team 3 – Dr. Eric Y F Cheung Team 4 – Dr. Andrew S H Ng PRAS – Dr. David S Y Wong PSU – Dr. Edwin K W Chan & Dr. Vicky H Y Wong URO – Dr. C K Chan & Dr. Samuel C H Yee CTS – Prof. Calvin S H Ng Mr. Alfred Chan Ms. Daisy Feng Mr. Philip Yeung Ms. Eunice Tam
Items discussed Complications report – August 2014 AOB
1. Complications Report – August 2014
August 2014 Summary (case collection progress and Complication rate) PRS NS PSUR URO CTS Dept. total Total cases 85 49 63 31 59 58 54 78 67 542 Missing cases 6 Non-Discharged * 4 1 2 3 14 Complication rate and Magnitude Team 1 Team 2 Team 3 Team 4 PRAS NS PSUR URO CTS Total No. of Complication 8 14 4 3 13 1 22 72 84 48 63 31 59 58 54 78 67 542 Complication Rate 9.52% 29.17% 6.35% 12.9% 5.08% 22.41% 5.56% 1.28% 32.84% 13.28%
Team 1 – Hepato-biliary and Pancreatic Surgery
Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 2/7) A good learning case for trauma management M&M
Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 3/7) Dr. Ray Hung – to review the micro-organism relating to small bowel perforation causing gastritis
Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 4/7)
Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 5/7)
Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 6/7)
Team 1 – Hepato-biliary and Pancreatic Surgery ( Cont’d 7/7) > 30 days mortality
Team 2 – Upper Gastro-intestinal Surgery
Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 2/7) pneumonia
Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 3/7) Further action : to arrange a follow-up scan for safety
Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 4/7) Converted open from robotic surgery
Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 5/7) M&M Very difficult to identify DJ flexure
Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 6/7)
Team 2 – Upper Gastro-intestinal Surgery ( Cont’d 7/7)
Team 3 – Colorectal Surgery
Team 3 – Colorectal Surgery ( Cont’d 2/4)
Team 3 – Colorectal Surgery ( Cont’d 3/4) 4 hours 9 minutes relatively long because of decontamination Lesson to Learn Early decision making So as to minimize the OT duration
Team 3 – Colorectal Surgery (Cont’d 4/4)
Team 4 – Vascular Surgery
Team 4 – Vascular Surgery ( Cont’d 2/4)
Team 4 – Vascular Surgery ( Cont’d 3/4) Intra-abdominal collection Should be a Team 3 case
Team 4 – Vascular Surgery ( Cont’d 4/4)
Plastic, Reconstructive and Aesthetic Surgery
Plastic, Reconstructive and Aesthetic Surgery ( Cont’d 2/3) would enhance supervision
Plastic, Reconstructive and Aesthetic Surgery ( Cont’d 3/3)
Neurosurgery NS Cases not discussed
Neurosurgery ( Cont’d 2/11)
Neurosurgery ( Cont’d 3/11)
Neurosurgery ( Cont’d 4/11)
Neurosurgery ( Cont’d 5/11)
Neurosurgery ( Cont’d 6/11)
Neurosurgery ( Cont’d 7/11)
Neurosurgery ( Cont’d 8/11)
Neurosurgery ( Cont’d 9/11)
Neurosurgery ( Cont’d 10/11)
Neurosurgery ( Cont’d 11/11)
Paediatric Surgery & Paediatric Urology
Paediatric Surgery & Paediatric Urology ( Cont’d 2/3) Complication was revealed with open disclosure Needed post-op chemotherapy
Paediatric Surgery & Paediatric Urology ( Cont’d 3/3)
Urology
Urology ( Cont’d 2/3)
Urology ( Cont’d 3/3) M&M Learning point - Not to put drain in closed system
Cardiothoracic Surgery
Cardiothoracic Surgery ( Cont’d 2/15)
Cardiothoracic Surgery ( Cont’d 3/15)
Cardiothoracic Surgery ( Cont’d 4/15)
Cardiothoracic Surgery ( Cont’d 5/15)
Cardiothoracic Surgery ( Cont’d 6/15)
Cardiothoracic Surgery ( Cont’d 7/15)
Cardiothoracic Surgery ( Cont’d 8/15) Should top-up nutritional support
Cardiothoracic Surgery ( Cont’d 9/15)
Cardiothoracic Surgery ( Cont’d 10/15)
Cardiothoracic Surgery ( Cont’d 11/15)
Problem of losening of suture Cardiothoracic Surgery ( Cont’d 12/15) Problem of losening of suture
Cardiothoracic Surgery ( Cont’d 13/15)
Cardiothoracic Surgery ( Cont’d 14/15)
Cardiothoracic Surgery ( Cont’d 15/15)
2. AOB
AOB PPCMP report – will incorporate “Rolling bar chart” showing performance for each team across a time-line. SOMIP – explore the development of risk calculator based on retrospective data (25 data fields)
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