Patient safety in surgical settings: what do we know? - Research Corner - Statistical Data Included

AORN Journal,  Jan, 2002  by Suzanne C. Beyea

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It is a given that clinicians who work with surgical patients have the best of intentions, and they strive to ensure patient safety and provide quality care. What is unclear, however, is the nature and extent of adverse events and errors related to surgery. Perhaps even less is known about creating a culture of safety in surgical settings and how to substantially minimize the frequency of adverse events and negative outcomes.

In 1999, the Institute of Medicine released its report To Err is Human: Building a Safer Health System. (1) This shocking report estimates that 44,000 to 98,000 deaths occur annually as a result of medical errors, including medication errors, surgical mistakes, and surgical complications. It is estimated that the total national cost for medical errors is between $8.5 and $17 billion annually. This report shocked the health care industry and consumers alike and has led to a number of regulatory, government, employer, and provider efforts to monitor and ensure safety in the health care environment.

MEDICAL ERRORS AND YOU

What does this report and subsequent reports about medical errors mean to perioperative nurses? First and foremost, medical errors do not occur as the result of "bad people." They more likely are the result of systems that are flawed, contributing to clinicians making mistakes. Frontline operators cause the active error at the "sharp end," and organizational factors (ie, flawed systems) result in latent error at the "blunt end." Traditions in health care have resulted in placing blame for errors on the clinician who caused the active error without considering flawed systems that may have contributed significantly to the error. According to one physician,

   Medical harm, by and large, is not the result of ignorance, malice,
   laziness, or greed on the part of the people or organizations involved....
   Systems can be created that will reduce the probability that these mistakes
   will occur.... (2)

For example, a preoperative patient is scheduled to receive a prophylactic antibiotic. The nurse is late in administering the medication, and this is classified as an error. If the patient develops a postoperative infection, an adverse event has occurred. The blame might be placed on the nurse for administering the medication late; however, organizational factors might have contributed to the problem. Perhaps the pharmacy was not open and the medication was not dispensed in a timely manner, or perhaps the physician forgot to write the order. Obviously, these represent organizational factors that contributed to the nurse's error. Without addressing flawed systems that contribute to errors, these errors can recur and lead to further adverse events.

WHAT IS HAPPENING IN THE OR?

For perioperative nurses, the question remains what types of errors and adverse events occur in the OR and other surgical settings. In a review of the pertinent literature, it is clear there are incomplete data, knowledge, and understanding about surgical adverse events. There is, however, evidence that supports the premise that adverse events are occurring and that many errors could be eliminated or reduced significantly.

In one of the first studies reporting preventable errors, researchers examined 30,000 hospitalizations in New York in 1984. (3) They reported that 3.7% of patients experienced serious adverse events related to medical management. The top three causes were related to medications (19%), wound infections (14%), and technical complications (13%). All of these events led to disability or prolonged stay, and 13.6% eventually led to death. Perhaps the most startling information from this report is that 58% of these events were classified as preventable mistakes.

A subsequent research effort examined the incidence and nature of adverse events in Colorado and Utah in 1992. (4) In this study, 66% of all adverse events were surgical in nature. Adverse events included technique-related complications, postoperative bleeding, infections of all types, medication-related injury, and deep venous thrombosis. Approximately 12% of all hospital deaths were associated with a surgical adverse event. Considering all adverse events, 54% were deemed preventable.

Canadian researchers report somewhat similar findings regarding surgical adverse events. Examining 192 general surgery patients for 1,277 days, they reported that 39% of patients suffered a total of 144 complications. Two of these complications were fatal, and 10 were life threatening. Of the 144 complications, 26 (18%) were considered preventable. Seventy-eight percent of the adverse events occurred during or after surgery. Of particular interest is that 80% of these adverse events were never reviewed during morbidity and mortality rounds, and 95% were not recorded on the discharge summary. (5)

Knowledge regarding errors in the outpatient surgical setting is limited. One report provides some insight into some of the problems associated with liposuction. In a census survey, the mortality rate for liposuction was reported as 19.1 per 100,000. Thromboembolism was cited as the number one cause of death. Most of these deaths (77.7%) occurred in an outpatient setting, but it is not clear how they related to medical errors. Researchers speculate that procedural risk factors and lack of medical supervision during the postoperative period were major factors contributing to negative outcomes. (6) It is possible that latent errors, such as discharging patients home rather than admitting them for observation, contributed to some of these deaths.