Nurses making a difference one life at a time - Patient Safety First

AORN Journal, May, 2002 by Suzanne C. Beyea

Perioperative nurses have a long and distinguished tradition of promoting patient safety by intervening to minimize the risks related to surgical infection and injury. By taking these actions in surgical settings, nurses are making a difference, one life at a time. Recent research, however, provides evidence that the ever-increasing complexity of care, technology, and the health care system are contributing to serious adverse events and negative patient outcomes in all types of clinical settings.

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. According to the report, 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.

A particular concern is the fact that

   surgical errors often appear the worst.... The end points in surgery are
   often more concrete and immediate than in medicine-survival or death, cure
   or failure. (2)

For perioperative nurses and surgical clinicians, questions remain unanswered about the exact nature of errors and adverse events that 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.

RESEARCH ON ERRORS

In one of the first studies reporting preventable errors, researchers examined 30,000 hospitalizations in New York in 1984. (3) These researchers 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. In a study of 192 general surgery patients for a period of 1,277 days, they reported that 39% of the 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 and adverse events in outpatient surgical settings remains 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.

An analysis of data from the National Patient Safety Bench-marking Center, Safety-Centered Solutions, Inc, shows that the five most financially costly adverse events are related to surgery, non-surgical treatment, nosocomial infections, medication errors, and pressure ulcers. These adverse events account for 81.5% of the total costs in the center's database. The most common adverse events listed in the database are related to surgery (20%), medication errors (16%), nonsurgical treatment (14.8%), patient falls (8.8%), and nosocomial infections (7.5%). (7)

AORN'S COMMITMENT

AORN is committed to providing quality, safe patient care, thus preventing errors and adverse events during the perioperative phases of care. Although these efforts have been ongoing, AORN is renewing its commitment. AORN's President, Board of Directors, and staff members are enthusiastically approaching this initiative with energy and focus. AORN also is seeking feedback from its members to learn how these initiatives can be targeted to address clinical needs, problems, and concerns.