Error traps and culture of safety in anorectal malformations

Attempting to decrease iatrogenic injuries and preventable harm, safety initiatives have become a priority in surgery. For adult hepatobiliary surgery, it has become common to study and consider "error traps" or common pitfalls that exist for laparoscopic cholecystectomy.^1-4 Extending this work to children, we have attempted to apply some of these initiatives by identifying error traps common to the care of patients born with anorectal malformations (ARM).

Five error traps were identified based on a retrospective analysis of operative records and radiographic studies from 398 re operative ARM cases performed by the authors. Once identified, the authors constructed a specific safety plan for each trap to promote a culture that will hopefully prevent ARM iatrogenic injuries.

The identified error traps are: 1) creation of a colostomy too distal in the sigmoid colon, 2) inaccurate distal colostogram and definition of the patient's preoperative anatomy 3) absence of a Foley catheter during the repair of an ARM in males and the hazards of separating the anterior rectal wall from the genito-urinary (GU) tract 4) mismanagement of a post-operative anal stricture following an ARM reconstructive procedure 5) limited or unstructured follow up of these patients. For each of the five traps the authors present suggestions for their avoidance.

The repair on an anorectal malformation is an elective procedure and while not completely avoidable, there should be little tolerance for iatrogenic injury and preventable harm. A culture of safety should be followed, beginning with a recognition of the common error traps associated with ARM procedures.