Continuous Monitoring of Adverse Events: Influence on the Quality of Care and the Incidence of Errors in General Surgery

Rebasa, Pere; Mora, Laura; Luna, A. Bayés de; Montmany, Sandra; Vallverdú, Helena; Navarro, Salvador

doi:10.1007/s00268-008-9848-6

Cited by 44 publications

(33 citation statements)

References 33 publications

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“…This finding is in accordance with a previous study on complications and errors in surgical patients 27 . In another study of medical errors, technical failure was also one of the most frequent errors encountered 23 . In contrast, nurses are more likely to register medication errors, as illustrated in a study of adverse events, where more than 90 per cent of the events were recorded by nurses 28 ; the most common events (33 per cent) were medication-related, and surgical technical errors were hardly recorded.…”

Section: Discussionmentioning

confidence: 98%

“…The incidence of error was similar in the present investigation, ranging from 3·9 to 9·9 per cent depending on the surgical subspecialty under investigation. Studies addressing the incidence of errors in surgical patients have reported rates of 10·5 and 6·9 per cent respectively 6,23 . These figures are quite similar to the present results.…”

Section: Discussionmentioning

confidence: 99%

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Incidence, nature and impact of error in surgery

Bosma

Veen

Roukema

2011

British Journal of Surgery

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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Incidence, nature and impact of error in surgery

Bosma

Veen

Roukema

2011

British Journal of Surgery

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“…Many available error studies have reported only the incidence and pattern of medical errors and adverse events. Rebasa et al, 28 who performed a similar study, assessed only the change in the percentage of patients with errors over time, unlike the present study in which we assessed many variables, including the change in the number of errors per patient, proportion of patients with errors, severity of errors, preventability of errors, clinical impact of errors, complications of errors, and types of errors. The significant improvement noted in these error parameters in response to information from error reporting appears to make this study unique and versatile in providing information to health institutions yet to be convinced about the importance of error recording and reporting.…”

Section: Resultsmentioning

confidence: 69%

A reduction in errors is associated with prospectively recording them

Oremakinde

Bernstein

2014

JNS

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Object Error recording and monitoring is an important component of error prevention and quality assurance in the health sector given the huge impact of medical errors on the well-being of patients and the financial loss incurred by health institutions. With this in mind, assessing the effect of reporting errors should be a cause worth pursuing. The object in this study was to examine the null hypothesis that recording and publishing errors do not affect error patterns in a clinical practice. Methods Intraoperative errors and their characteristics were prospectively recorded between May 2000 and May 2013 in the neurosurgical practice of the senior author (M.B.). The error pattern observed between May 2000 and August 2006, which has been previously described (Group A), was compared with the error pattern observed between September 2006 and May 2013 (Group B). Results A total of 1108 cases in Group A and 974 cases in Group B were surgically treated. A total of 2684 errors were recorded in Group A, while 1892 errors were recorded in Group B. The ratios of cranial to spinal procedures performed in Groups A and B were 3:1 and 10:1, respectively, while the ratios of general to local anesthesia in the two groups were 2:1 and 1.3:1, respectively (p < 0.0001 for both). There was a significantly decreased proportion of cases with error (87% to 83%, p < 0.006), mean errors per case (2.4 to 1.9, p < 0.0001), proportion of error-related complications (16.7% to 5.5%, p < 0.002), and clinical impacts of error (2.7% to 1.0%, p < 0.0001) in Group B compared with Group A. Errors in Group B tended to be more preventable than those in Group A (85.8% vs 78.5%, p < 0.0001). A significant reduction was also noticed with most types of error. A descending trend in the mean errors per case was demonstrated from the years 2001 to 2012; however, an increased severity of errors (22.6% to 29.5%, p < 0.0001) was recorded in Group B compared with Group A. Conclusions Data in this study showed that the act of recording errors might alter behaviors, resulting in fewer errors.

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“…Abdominal wound dehiscence was reported was reported at a mean of 9 th postoperative day (6)(7)(8)(9)(10)(11)(12)(13)(14)(15). One patient reported with dehiscence after discharge from hospital after removal of sutures from a local hospital.…”

Section: Resultsmentioning

confidence: 99%

“…6,7 In addition there is an increase in the cost of the care both in terms of increased hospital stay, nursing and manpower cost in managing the burst abdomen and its complication. [8][9][10][11][12] The disruption of the wound tends to occur a few days beforehand when the sutures opposing the deep layers tear through or even become untied. An incisional hernia starts as a symptomless partial disruption of the deep layers during the immediate or early postoperative period, even this passes unnoticed if the skin wound remains intact after the skin sutures have been removed.…”

Section: Introductionmentioning

confidence: 99%

KIMS 14: a new scoring system to predict abdominal wound dehiscence following emergency laparotomy

et al. 2017

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Background: Abdominal wound dehiscence is a common complication of emergency laparotomy in Indian setup. Wound dehiscence carries with it a substantial morbidity and mortality. Hence, we have developed a scoring system which can predict wound dehiscence following emergency laparotomy and prophylytic measures can be taken preoperatively to prevent this. Objectives were to identify independent risk factors for abdominal wound dehiscence and to develop a scoring system to recognize high risk patients.Methods: An observational, longitudinal, analytical and retrospective study was done from July 2014 to January 2017 in KIMS Hubli, Karnataka, India, where the sample studied were patients who underwent midline laparotomy during the study period. 30 cases of abdominal wound dehiscence were taken and 60 controls.Results: 30 cases of abdominal wound dehiscence following emergency laparotomy were reported and compared with 60 selected controls. Age, gender duration of symptoms hypotension, anemia hyperbilirubinemia, hypoproteinemia, uremia, duration of surgery, contaminated wounds, COPD/chest infections were statistically significant. Multivariate binary logistic regression showed Hypoproteinemia, uremia duration of surgery contaminated wounds and chest infection/COPD as independent significant risk factor and a scoring system was developed using these variables.Conclusions: The scoring system developed can identify the high-risk patients and necessary measures can be taken to prevent this complication.

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Continuous Monitoring of Adverse Events: Influence on the Quality of Care and the Incidence of Errors in General Surgery

Abstract: This is the first attempt to determine the prevalence of errors in surgery. Introducing systematic programs for recording adverse events can reduce error rates and promote a culture of patient safety in a General Surgery Department.

Cited by 44 publications

References 33 publications

Incidence, nature and impact of error in surgery

Incidence, nature and impact of error in surgery

A reduction in errors is associated with prospectively recording them

KIMS 14: a new scoring system to predict abdominal wound dehiscence following emergency laparotomy

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