title: An investigation into the causes of unexpected intra-operative transoesophageal echocardiography findings.
abstract: There is uncertainty regarding echocardiography before cardiac surgery, especially with regard to timing and disease progression as well as potential errors. We investigated the causes of unexpected intra-operative transoesophageal echocardiography findings by performing a 33-month audit. We found that there were 50/797 (6%) unexpected findings that led to an alteration in surgical strategy in 34 (4%) patients. Of the unexpected findings, 25 (50%) were unrelated to pre-operative pathology. After reviewing pre-operative studies and reports, unexpected findings were found to be due to: reporting errors in 20 patients (44%); limitations in transthoracic compared to transoesophageal echocardiography in 14 patients (30%); disease progression in 10 patients (22%); and inter-observer variability in two patients (4%). We identified six reports out of 797 (0.8%) that contained potentially serious errors. Surgical management changed in 18/20 (90%) patients in whom the unexpected change was due to reporting error, compared to 16/30 (53%) patients whose pre-operative echocardiogram was correctly reported (p = 0.006). Our study suggests that pre-operative echocardiography reporting errors are common and important.
authors.affiliation: Trent Cardiac Centre, Nottingham University Hospitals, Nottingham, UK. henry.skinner@nuh.nhs.uk
authors.forename: H J
authors.initials: HJ
authors.lastname: Skinner
authors.forename: A
authors.initials: A
authors.lastname: Mahmoud
authors.forename: A
authors.initials: A
authors.lastname: Uddin
authors.forename: T
authors.initials: T
authors.lastname: Mathew
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures; D003951:Diagnostic Errors / Q000706:statistics & numerical data; D018450:Disease Progression; D004452:Echocardiography / Q000379:methods / Q000706:statistics & numerical data; D017548:Echocardiography, Transesophageal / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods* / Q000706:statistics & numerical data; D015588:Observer Variation; D011300:Preoperative Care / Q000379:methods / Q000706:statistics & numerical data; D011446:Prospective Studies