Occurrence and prevention of surgical adverse events for quality improvement of surgical care.

Zegers, M., Bruijne, M.C. de, Wagner, C., Groenewegen, P.P., Wal, G. van der. Occurrence and prevention of surgical adverse events for quality improvement of surgical care. Abstract. ISQUA Congress "Healthcare Quality and Safety. Meeting the Next Challenges" 19-22 oktober 2008, Copenhagen, Denmark. 122
Objective: To assess the occurrence, impact, type of adverse outcomes, causes and preventability of surgical adverse events (AEs) among hospitalised patients for quality improvement of surgical care. Methods: A retrospective patient records review study was performed in a random sample of 7926 patient records from 2004 of 21 Dutch hospitals. The records were screened by trained nurses using 18 explicit screening criteria indicating potential AEs. Records screened positive were independently reviewed by two trained physicians, to determine presence, impact, type of injury and degree of preventability of AEs. An adverse event was defined as an unintended injury among hospitalised patients that resulted in disability, death or prolonged hospital stay, and was caused by health care management. Preventable was defined as care that fell below the current level of expected performance for practitioners or systems. If there was disagreement about the presence and/or preventability of an AE between the two independent physician reviews, they started a consensus procedure to obtain consensus or a third trained physician reviewer gave a final judgement. A surgical AE was defined as an AE occurring under responsibility of surgical specialties. For all surgical AEs, the adverse outcomes, causes and prevention strategies were registered (more options per AE). Patient and admission characteristics were obtained from the Dutch registration of hospital information. Results: The incidence of AEs in the Dutch Adverse Event Study was 5.7% (95% CI 5.1-6.4). Of all AEs (n=744), 64.5% were attributable to surgical specialties. Surgical AEs were more often preventable, but resulted less often in permanent disability and death compared to non-surgical AEs. Of all surgical AEs, 39% were attributable to general surgery, 14% to orthopaedics, and 8% to heart/thorax surgery. Degree of preventability and permanent disability (including death) of surgical AEs increased with age. More surgical AEs occurred in university hospitals (4.9%; 95% CI 3.5-6.8) compared to general hospitals (2.6%; 95% CI 2.1-3.4). However, surgical AEs in general hospitals were more often preventable. Elective admissions were more often associated with surgical AEs (5.8%; 95% CI 4.8- 6.9) compared to urgent admissions (2.0%; 95% CI 1.5-2.6). Of all surgical AEs, 19.5% of the patients had a diagnosis related to injury and poisoning, 15.0% to neoplasms, 11.9% to diseases of the musculoskeletal system and connective tissue, and 11.5% to diseases of the circulatory system. Most frequent adverse outcomes were inflammation/infection (27.3%), bleeding/haematoma (19.8%), complication by mechanic and physical-chemical causes (21.9%), like joint luxation and perforation, and impairments in the healing process (8.9%), such as wound dehiscence and stenosis. Causal factors were judged predominantly human (61.5%) and patient related (42.6%), and less often organisational (12.7%), and technical (4.4%). Recommended prevention strategies included intercollegial quality monitoring (72.9%), training (58.9%), and reflection (51.4%). Conclusions: AEs related to surgical specialties are more common but less severe than AEs related to non-surgical specialties and most of the surgical AEs were caused by human factors. Prevention strategies to minimise the occurrence of (post) operative injuries should focus on intercollegial quality monitoring, training for improvement of skills, and reflection of the current way of behaving regarding safety. (aut. ref. )