Complications are common in hospitalized surgical patients. Provider error contributes to a significant proportion of these complications.
Surgical patients were concurrently observed for the development of explicit complications. All complications were reviewed by the attending surgeon and other members of the service and evaluated for the severity of sequelae (major or minor) and for whether the complication resulted from medical error (avoidable) or not.
University teaching hospital with a level I trauma designation.
All inpatients (operative or nonoperative) from 4 different surgical services: general surgery, combined general surgery and trauma, vascular surgery, and cardiothoracic surgery.
Total complication rate (number of complications divided by the number of patients) and the number of patients with complications. Complications were separated into those with major or minor sequelae and the proportion of each type that were due to medical error (avoidable). Rates of complications in a recent Institute of Medicine report were used as a criterion standard.
The data for the respective groups (general surgery, vascular surgery, combined general surgery and trauma, and cardiothoracic surgery) are as follows. The number of patients was 1363, 978, 914, and 1403; number of complications, 413, 409, 295, and 378; total complication rate, 30.3%, 42.4%, 32.3%, and 26.9%; minor complication rate, 13.3%, 19.9%, 13.5%, and 13.0% (percentage of minor complications that were avoidable, 37.4%, 59.0%, 51.2%, and 49.5%); major complication rate, 16.2%, 21.1%, 18.1%, and 12.9% (percentage of major complications that were avoidable, 53.4%, 60.7%, 38.8%, and 38.7%); and mortality rate, 1.83%, 3.33%, 2.28%, and 3.34% (percentage of mortality that was avoidable, 28.0%, 44.1%, 19.0%, and 25.0%).
Despite mortality rates that compare favorably with national benchmarks, a prospective examination of surgical patients reveals complication rates that are 2 to 4 times higher than those identified in an Institute of Medicine report. Almost half of these adverse events were judged contemporaneously by peers to be due to provider error (avoidable). Errors in care contributed to 38 (30%) of 128 deaths. Recognition that provider error contributes significantly to adverse events presents significant opportunities for improving patient outcomes.
"In that context, safety and quality have become prominent criteria in the evaluation of surgical care. The incidence of postoperative complications in patients subjected to colorectal surgery has been shown to vary between 17% and 31% in investigations of both elective and emergent procedures [4,5]. In recent reports, postoperative complications increased health care costs and resource utilization [6,7]. "
[Show abstract][Hide abstract] ABSTRACT: Postoperative complications contribute to morbidity and mortality. This study assessed the impact of surgical complications on healthcare resource utilization for patients undergoing elective colorectal procedures.
Data were obtained on 530 consecutive colorectal operations performed from January 2010 to January 2011. Patient demographics, type of procedure, surgical complications classified as Clavien 1-5, length of stay, 60-day readmission rate, and hospital costs were recorded.
Seventy-five percent of the operations were associated with malignancy, and 26% were pelvic procedures. Thirty-five percent of the patients developed at least one complication, 21% of the complications did not require intervention. The readmission rate was 7.4%. Nine patients died during 60-day post discharge follow up.Median length of stay was 9 (3-34) days in uncomplicated and 16 (4-205) days in complicated cases. Occurrence of any complication at index admission increased total hospital costs 2.1-fold (EUR 25,680 vs. EUR 12,405), with the largest cost differential attributed to wound dehiscence and/or suture line failure requiring reoperation. These increases were primarily due to prolonged hospitalization and ICU expenditures. Readmission resulted in a further increase to an average cost of EUR 12,585 per re-admitted patient.Multivariate analysis showed that BMI > 25, obesity, operation complexity and surgeon significantly affected the risk for complication. Also, hospital costs were significantly increased by any postoperative complications, reoperations, high complexity of surgical procedures and high comorbidity index.
Reducing morbidity after colorectal procedures improves quality of care and patient safety, and may also substantially reduce hospital costs and increase the efficiency of resource utilization.
Patient Safety in Surgery 01/2014; 8(1):2. DOI:10.1186/1754-9493-8-2
"For example, an analysis of 1200 completed hospital cases by Health Care Risk Resources International found that operating theatres were 'high risk' and that within the processes of surgical care the greatest risk to safety was 'unintentional damage' to the patient (28%), followed by 'diagnostic error' (27%) (Wilson, 1999). A prospective examination of outcomes for over 4,500 surgical patients in a US University teaching hospital suggested that between thirty and fifty per cent of major complications in patients undergoing general surgical procedures are avoidable (Healey et al, 2002). One recent study suggested that the probable incidence of error in the surgical intensive care unit is potentially as great as one in every two patients (Krizek, 2000), and another retrospective case review detected that up to 16.2% of General Surgery records contained instances of 'adverse events' (Vincent et al, 2001). "
[Show abstract][Hide abstract] ABSTRACT: Current thinking about "patient safety" emphasises the causal relationship between the work environment and the delivery of clinical care. This research draws on the theory of normal accidents to extend this analysis and better understand the "organisational factors" that threaten safety.
Ethnographic research methods were used, with observations of the operating department setting for 18 month and interviews with 80 members of hospital staff. The setting for the study was the Operating Department of a large teaching hospital in the North-West of England.
The work of the operating department is determined by inter-dependant, "tightly coupled" organisational relationships between hospital departments based upon the timely exchange of information, services and resources required for the delivery of care. Failures within these processes, manifest as "breakdowns" within inter-departmental relationships lead to situations of constraint, rapid change and uncertainty in the work of the operating department that require staff to break with established routines and work with increased time and emotional pressures. This means that staff focus on working quickly, as opposed to working safely. ORIGINALITY VALUE: Analysis of safety needs to move beyond a focus on the immediate work environment and individual practice, to consider the more complex and deeply structured organisational systems of hospital activity. For departmental managers the scope for service planning to control for safety may be limited as the structured "real world" situation of service delivery is shaped by inter-department and organisational factors that are perhaps beyond the scope of departmental management.
Journal of Health Organisation and Management 02/2006; 20(2-3):227-42. DOI:10.1108/14777260610662753 · 0.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: The Institute of Medicine’s 2000 report entitled To Err is Human states that as many as 98,000 people die each year as a result of medical error in the United States. Subsequent studies indicate that this may be an underestimate. Awareness of the patient safety problem has led to widespread attempts to encourage quality improvement in America, from legislation requiring incident reporting to pay-for-performance programs. Evaluating and improving process design has been recognized as a critical element in improving patient safety. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) recommends a technique called failure mode effect and criticality analysis (FMECA), which has been widely used in improving the safety of medical processes. This tool’s uses are limited because of its inability to examine the possibility of multiple errors occurring in a process. Methods: Efforts were centered on the creation of a generalizable schema that could be used in creating models more descriptive of the possibility of multiple errors contributing to undesirable outcomes. For this purpose, we used a Bayesian Network (BN) to incorporate both the process flow diagram and the probabilities/frequencies of various failures and their consequences for a given procedure. Steps from process flow diagrams used in creating FMECAs are categorized into action steps and validation steps, which are organized with potential outcomes and probabilities into a resulting matrix that represents all possible combinations of errors as well as the probability that any given error (or combination of errors) will occur. The model is first used as an influence diagram to determine which possible branches in a chain of steps may be eliminated. Once branches with higher probabilities of error are eliminated, the streamlined BN will indicate the probability that any outcome is reached by any combination of steps with any combination of errors. An existing FMECA completed for blood transfusion is used to illustrate our method. Results: The resulting model is useful for several reasons. Decision analysis can be performed to ascertain what potential errors can simply be eliminated from the process. High probability errors are noticeable, but more importantly, dangerous combinations of error are highlighted. Depending on the level of specificity achieved in the initial FMECA, specific health outcomes can be attached to specific errors, creating a diagnostic tool for use in later root-cause analyses. The model can be adjusted readily, so proposed changes in the process can be examined in a hypothetical setting before being tested in an actual health care setting. Conclusion: Creation of a BN model increases the value of time intensive labor already performed during FMECAs. This method shares some of the benefits of more sophisticated modeling approaches but builds off of the widely used FMECA framework already recommended by JCAHO. It achieves the goal of determining which combinations of error lead to undesired outcomes.
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