The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies

Abstract

BackgroundWe need to know the scale and underlying causes of surgical adverse events (AEs) in order to improve the safety of care in surgical units. However, there is little recent data. Previous record review studies that reported on surgical AEs in detail are now more than ten years old. Since then surgical technology and quality assurance have changed rapidly. The objective of this study was to provide more recent data on the incidence, consequences, preventability, causes and potential strategies to prevent AEs among hospitalized patients in surgical units.MethodsA structured record review study of 7,926 patient records was carried out by trained nurses and medical specialist reviewers in 21 Dutch hospitals. The aim was to determine the presence of AEs during hospitalizations in 2004 and to consider how far they could be prevented. Of all AEs, the consequences, responsible medical specialty, causes and potential prevention strategies were identified. Surgical AEs were defined as AEs attributable to surgical treatment and care processes and were selected for analysis in detail.ResultsSurgical AEs occurred in 3.6% of hospital admissions and represented 65% of all AEs. Forty-one percent of the surgical AEs was considered to be preventable. The consequences of surgical AEs were more severe than for other types of AEs, resulting in more permanent disability, extra treatment, prolonged hospital stay, unplanned readmissions and extra outpatient visits. Almost 40% of the surgical AEs were infections, 23% bleeding, and 22% injury by mechanical, physical or chemical cause. Human factors were involved in the causation of 65% of surgical AEs and were considered to be preventable through quality assurance and training.ConclusionsSurgical AEs occur more often than other types of AEs, are more often preventable and their consequences are more severe. Therefore, surgical AEs have a major impact on the burden of AEs during hospitalizations. These findings concur with the results from previous studies. However, evidence-based solutions to reduce surgical AEs are increasingly available. Interventions directed at human causes are recommended to improve the safety of surgical care. Examples are team training and the surgical safety checklist. In addition, specific strategies are needed to improve appropriate use of antibiotic prophylaxis and sustainable implementation of hygiene guidelines to reduce infections.

The design, development, and implementation of a checklist for intraoperative neuromonitoring changes

“…26,30,53 Checklists for surgery are being pursued due to the increasing recognition that errors in surgery are possible, may result in harm, and may be preventable. The experience with checklists in surgery draws heavily from the aviation industry.…”

Making Decisions in a Virtual Operating Room

“…Zegers [3] conducted a study in 21 Dutch hospitals in 2004 whose results showed that surgical adverse events represented 65% of all adverse events. In 1999, Gawande et al [4] studied 15,000 randomly medical records of patients from Utah and Colorado hospitals.…”

Research Paper: Risk Assessment of Surgical Procedures in a Referral Hospital

“…Death as a result of an AE, prolonged hospital (surgical ward) stay, extra treatment (extra intervention), readmission to the hospital (surgical ward), temporary or permanent disability at the time of discharge (after surgery), suboptimal care, physical injury, mental injury, inconvenience [11,15], Lack of treatment audit before starting procedures, misidentification, exceeded workload, legal liability, and unidentified.…”