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Am J Surg. 2018 Nov;216(5):846-850. doi: 10.1016/j.amjsurg.2018.03.005. Epub 2018 Mar 6.

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes.

Author information

1
Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA. Electronic address: qi.chen2@va.gov.
2
Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA.
3
Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Department of Anesthesiology, Critical Care and Pain Medicine, VA Boston Healthcare System, Boston, MA, USA.
4
Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.
5
Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA; Department of Surgery, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.

Abstract

Our knowledge of the types of intraoperative patient safety events, their harm to patients, and relationship to postoperative complications is sparse. This study examined intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) voluntarily reported by providers using two programs at our hospital: surgical debriefing and incident reporting. Among the 3020 surgical procedures assessed, 142 iMEs and 103 iAEs were reported, yielding an overall rate of 8%. Of these events, 135 (55%) were obtained from incident reporting and 110 (45%) from surgical debriefing. The overall association between intraoperative events (iMEs and iAEs) and 30-day postoperative morbidity was significant (adjusted odds ratio = 1.08 with 95% confidence interval (CI) of (1.03, 1.13). This association was stronger when we included only the iAEs (1.47, 95% CI (1.35, 1.58)). Our findings suggest that hospitals should consider using both programs to obtain a more complete picture of intraoperative patient safety and to reduce postoperative morbidity.

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