Preventable Morbidity and Mortality Among Non‐trauma Emergency Surgery Patients: The Role of Personal Performance and System Flaws in Adverse Events

Abstract

Background Preventable morbidity and mortality among emergency surgery patients is not adequately analyzed. We aim to describe and classify preventable complications and deaths in this population. Methods The medical records and quality control documents of patients with emergency, non-trauma, surgical disease admitted between September 1, 2006, and August 31, 2018, and recorded to have a preventable or potentially preventable morbidity and mortality were reviewed. The primary outcome was a classification of the complications and deaths by a panel of experts, as attributable to issues of personal performance or system deficiencies. Results One hundred and fifty patients were identified (127 complications and 23 deaths). The most commonly encountered preventable complications were surgical-site infection (17%), bleeding (13%), injury to adjacent structures (12%), and anastomotic leak (8%). The majority of complications seemed to stem from personal performance (97%), due to either technical or judgment issues, and only 3% were linked with system flaws, either in the form of communication or inadequate protocols. Alcohol use disorder and duration of operation were different between patients with preventable adverse events related to technical issues and patients related to judgment issues; furthermore, more patients who experienced judgment issues died during hospital stay (p \0.05). Conclusion Among emergency surgery patients, who suffer preventable complications and deaths, issues related to personal performance are more frequent than system flaws. Whereas the effort to improve systems should be unwavering, the emphasis on the surgeon's personal responsibility to avoid preventable complications should not be derailed.