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Annals of Surgery Study: Failures in postoperative care after major elective general surgery.

Those of us who practice the high reliability mindset have come to understand there are ways to think about the big picture of managing critically ill patients to avoid mistakes.  However, as this study last month in the Annals of Surgery points out, process failures are common in postoperative care and frequently cause harm to patients. But with a systematic approach to error avoidance these events are highly preventable. This study shows that interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce adverse patient events and reduce costs and hospital stay.  Read this article and keep in mind all the methods that we have talked about in this blog over the last two years and try to see where we might apply our high reliability mindset in our own clinical practice to attain these goals.


Ann Surg. 2013 Jan;257(1):1-5. doi: 10.1097/SLA.0b013e31826d859b.  (Access to full post on Annals of Surgery website requires an account).

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

Symons NR, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K.

Source

Clinical Safety Research Unit, Department of Surgery and Cancer, Imperial College London, London, UK. n.symons@imperial.ac.uk

Abstract

OBJECTIVE:

To investigate the nature of process failures in postoperative care, to assess their frequency and preventability, and to explore their relationship to adverse events.

BACKGROUND:

Adverse events are common and are frequently caused by failures in the process of care. These processes are often evaluated independently using clinical audit. There is little understanding of process failures in terms of their overall frequency, relative risk, and cumulative effect on the surgical patient.

METHODS:

Patients were observed daily from the first postoperative day until discharge by an independent surgeon. Field notes on the circumstances surrounding any nonroutine or atypical event were recorded. Field notes were assessed by 2 surgeons to identify failures in the process of care. Preventability, the degree of harm caused to the patient, and the underlying etiology of process failures were evaluated by 2 independent surgeons.

RESULTS:

Fifty patients undergoing major elective general surgery were observed for a total of 659 days of postoperative care. A total of 256 process failures were identified, of which 85% were preventable and 51% directly led to patient harm. Process failures occurred in all aspects of care, the most frequent being medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. Process failures accounted for 57% of all preventable adverse events. Communication failures and delays were the main etiologies, leading to 54% of process failures.

CONCLUSIONS:

Process failures are common in postoperative care, are highly preventable, and frequently cause harm to patients. Interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce hospital stay.

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Posted in High Reliability Mindset, Patient Safety.

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