Document Detail

Incidence, nature and impact of error in surgery.
MedLine Citation:
PMID:  21706475     Owner:  NLM     Status:  Publisher    
BACKGROUND: Adverse events occur in 3·8-17 per cent of hospital admissions. The purpose of this study was to analyse the incidence of medical errors and assess the feasibility of an error registry for quality improvement programmes. METHODS: Errors were recorded prospectively in a complication registry between 1 June 2005 and 31 December 2007. Events were coded according to the Trauma Registry of the American College of Surgeons; the nature of events was recorded and the severity graded using the 1992 Clavien system. Recorded events were discussed by the medical staff on a daily basis and, if by consensus judged to be errors, were saved to the registry database. RESULTS: Of 12 121 patients admitted to the surgical ward during the study interval, 2033 (16·8 per cent) had a complication and 735 (6·1 per cent) had an error documented in the registry. Of 873 recorded errors, 607 (69·5 per cent) were of little or no consequence (Clavien grade I) and 220 (25·2 per cent) required therapeutic intervention (Clavien grade IIa and IIb). Errors leading to permanent injury (Clavien grade III) occurred in 41 instances (4·7 per cent) and five patients (0·6 per cent) died (Clavien grade IV). CONCLUSION: This study shows that errors are common in surgery, and that near misses are more frequent than errors with serious consequences. It is hypothesized that registration of near misses might prevent errors with serious consequences and thus improve quality of care. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
E Bosma; E J Veen; J A Roukema
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2011-6-27
Journal Detail:
Title:  The British journal of surgery     Volume:  -     ISSN:  1365-2168     ISO Abbreviation:  -     Publication Date:  2011 Jun 
Date Detail:
Created Date:  2011-6-27     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0372553     Medline TA:  Br J Surg     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Copyright Information:
Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
Department of Surgery, St Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands.
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