Death in low-risk cardiac surgery revisited

Abstract

BackgroundA systematic review of low-risk death has been shown successful in identifying system weaknesses. The aim was to analyse early mortality in low-risk patients undergoing cardiac surgery and to determine the cause of death, classify if they were unavoidable or potentially preventable as a result of technical or system errors.MethodsWe included all low-risk patients who underwent cardiac surgery at our institution from 1 September 2009 to 31 August 2019. In patients operated between 2009 and 2011, we defined low risk as an additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) I less than or equal to 3, and from 2012 and onwards as a EuroSCORE II less than or equal to 1.5. The medical records for the patients who died within 30 days of surgery were thoroughly examined and the cause of death was classified as cardiac or non-cardiac. Furthermore, deaths were categorised as not preventable, preventable (technical error) or preventable (system error).ResultsDuring the study period 3103 low-risk patients underwent surgery, and 11 patients died within 30 days of the operation (0.35%). Six of these (55%) were classified as preventable and five non-preventable. Four of the preventable deaths were classified as technical errors and two were due to system errors.ConclusionsA repeated systematic review of deaths in patients with a low preoperative risk showed that a majority of deaths were preventable, and therefore potentially avoidable. Similar to the previous assessment at our unit, mortality was very low and failure to communicate remains a modifiable factor that should be addressed.

Most deaths in low-risk cardiac surgery could be avoidable

“…Our study included all types of cardiac procedures, as well as a Sweden study, however our percentage of avoidable mortality was higher (75% vs. 55%) 5 . There are some important differences in both analyses: our study was multicentric, used a single patient selection risk score (EuroSCORE II) and the analysis of deaths was performed by an independent multidisciplinary POCMA team.…”

“…Undoubtedly, results will improve over time, with continuous quality improvement policies focused on discussions about the risk–benefit of surgery, surgery timing, and the adoption of strategies from highly reliable organizations 5 , 13 , 14 , 24 – 26 , since there are no improvements without identifying problems and measuring the results of surgical procedures 27 . As such, all discussions, especially for more complex cases, would result in a more balanced appraisal of the role of cardiac surgery in patients with a limited life expectancy.…”

“…Mortality rates due to cardiac surgery have been decreasing across the world 1 – 3 , however, avoidable deaths still occur in low-risk patients 4 , 5 . Traditional analysis methods of cardiac surgeries outcomes focus on adjusting mortality rates, without objectively analyzing the root causes of problems; therefore, nonsurgical factors lose significance and are often unknown and underexplored 4 .…”

“…In aviation, the cause of an accident begins with a seminal event that is always associated with other contributing factors; thus, a cascade of factors is aligned in a random process that influences the outcome. A system as complex and dynamic as civil aviation resembles the health system because its outcomes can be affected by multiple sequential factors 5 , 7 – 9 . To identify the root cause of death in cardiac surgery, objective methods are essential to enhance patient safety and improve results.…”

At the Crossroads of Minimally Invasive Mitral Valve Surgery—Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology

“…POCMA also provides a root cause analysis as well as an estimation of the magnitude of the risk [ 16 , 17 ]. Liden K et al and Mejia OA et al applied POCMA to low-risk cardiac surgery patients and concluded that even low-risks of mortality were avoidable [ 5 , 6 ].…”