Lessons Learned from an Erroneous Surgery : Inversely Implanted Apicoaortic Valved Conduit
10.4326/jjcvs.44.313
- VernacularTitle:Apico-Aortic Bypassにおいて人工弁を逆位に縫着した経験から学ぶ
- Author:
Takahiro Souma
;
Shuichiro Takanashi
- Publication Type:Journal Article
- Keywords:
Apico-Aortic Bypass;
human factor;
wrong surgery
- From:Japanese Journal of Cardiovascular Surgery
2015;44(6):313-317
- CountryJapan
- Language:Japanese
-
Abstract:
A 62-year-old woman with severe aortic stenosis underwent apicoaortic bypass grafting. The graft was implanted inversely at first ; on the next day, it was re-implanted in the right direction. She recovered once from heart failure ; however, on postoperative day (POD) 74, she died from respiratory failure. On POD 16, an in-house multidisciplinary investigatory commission reviewed the human factors that had led to the surgical error. Throughout the investigation, we provided relevant information about the event and explanations. We presented our apologies the patient's family and offered to compensate them for their losses.
