title: Medical errors: the performance gap in hypoplastic left heart syndrome and physiologic equivalents?
abstract: BACKGROUND
  The frequency and impact of medical errors during staged palliation are unknown.
  
  
  METHODS
  All patients with hypoplastic left heart syndrome and physiologic equivalents (N = 191) who underwent staged palliation (2001-2011) were studied. Stage 1, interstage, and stage 2 were reviewed to identify diagnostic, technical, judgment, and management errors. The impact of errors on transplant-free survival was examined by parametric competing risks and risk-adjusted regressions using bootstrapping.
  
  
  RESULTS
  Stage 1 (N = 191) errors (n = 111, 58%) were common and predominantly intraoperative (n = 84, 44%) or postoperative (n = 43, 23%). Postoperative errors were determinants of death/transplant (hazard ratio, 1.7; P = .01), whereas technical errors (n = 65, 34%) were not, but they delayed recovery and discharge (extra 24 days approximately, P = .0024). Postoperative stage 1 errors led to decrements in total strategy success of approximately 30% (78% vs 48%, P = .004). Stage 2 (N = 134) errors (n = 66, 49%) were common. Intraoperative errors were the most prevalent (n = 61, 46%) but did not compromise survival. Postoperative errors (n = 11, 8%) were determinants of death/transplant (hazard ratio, 2.4; P < .0001). Interstage errors (n = 21, 16%) led to twice the intensive care unit stay (16 vs 7 days, P < .0001) and hospital stay (30 vs 17 days, P < .02) after stage 2. Overall, a child presenting with ideal morphology and managed with no postoperative errors at stage 1 or 2 would have a predicted late survival in excess of 80%.
  
  
  CONCLUSIONS
  Technical errors are common and delay recovery. Their effects on survival are mitigated. Intraoperative judgment errors are associated with strategy failure in a univariate model and lead to increased postoperative errors in a multivariate model. Postoperative errors are independently associated with a decrease in univentricular strategy survival.
authors: Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
authors: Frederic
authors: F
authors: Jacques
authors: Vijay
authors: V
authors: Anand
authors: Edward J
authors: EJ
authors: Hickey
authors: Yasuhiro
authors: Y
authors: Kotani
authors: Mrinal
authors: M
authors: Yadava
authors: Abdullah
authors: A
authors: Alghamdi
authors: Christopher A
authors: CA
authors: Caldarone
authors: Andrew N
authors: AN
authors: Redington
authors: Steven
authors: S
authors: Schwartz
authors: Glen S
authors: GS
authors: Van Arsdell
mesh_terms: D006348:Cardiac Surgical Procedures / Q000592:standards*; D005260:Female; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000601:surgery*; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D019300:Medical Errors; D010166:Palliative Care; D012044:Regression Analysis; D012307:Risk Factors; D016896:Treatment Outcome