Error traps and culture of safety in Hirschsprung disease

Semin Pediatr Surg. 2019 Jun;28(3):151-159. doi: 10.1053/j.sempedsurg.2019.04.013. Epub 2019 Apr 25.

Abstract

Hirschsprung disease affects many children every year around the world. Currently, there is an extensive menu of diagnostic methods, and surgical treatments. This situation compels the physicians to follow the rationale of these interventions. The comprehensive diagnosis and treatment of Hirschsprung disease need singular procedures. The clear understanding of how to perform each of these techniques, as well as to read the results is mandatory. Otherwise, the medical team may perform unconscious errors and fall into traps. Many errors still happen in patients with Hirschsprung, resulting in a spectrum of problems; from delayed diagnosis to unnecessary colectomies. In other patients, the damage to the anal canal results in fecal incontinence. When this is established, it is an unreversed and devastating social problem. This article describes why these errors occur and how to prevent them.

Keywords: Colitis; Fecal incontinence; Hirschsprung; Megacolon; Safety culture.

Publication types

  • Review

MeSH terms

  • Biopsy / methods
  • Biopsy / standards*
  • Diagnostic Techniques, Digestive System / standards*
  • Fecal Incontinence / etiology
  • Fecal Incontinence / prevention & control*
  • Hirschsprung Disease / diagnosis*
  • Hirschsprung Disease / surgery*
  • Humans
  • Infant
  • Infant, Newborn
  • Intraoperative Complications / etiology
  • Intraoperative Complications / prevention & control*
  • Medical Errors*
  • Patient Safety / standards*
  • Postoperative Complications / etiology
  • Postoperative Complications / prevention & control*
  • Surgical Procedures, Operative / adverse effects
  • Surgical Procedures, Operative / methods
  • Surgical Procedures, Operative / standards*