Medical errors, ?near misses? during surgery are commonplace

July 12, 2011

Medical errors, ?near misses? during surgery are commonplace

By
Springer

MedWire News: Registration of surgical errors might help reduce the likelihood of those with major consequences, suggest study findings showing that medical errors during surgery are common, although over two-thirds result in little or no consequence for the patient.

"There are many near misses without consequences that can be recorded prospectively and analyzed in error prevention programs," say E Bosma (St Elisabeth Hospital, LC Tillburg, The Netherlands) and co-authors.

Between 2005 and 2007, surgical errors were prospectively recorded among 12,121 patients admitted to a surgical ward according to the Trauma Registry of the American College of Surgeons criteria.

Event severity was recorded and graded using the 1992 Clavien system: morbidity with no/very minor consequences (grade I); need for pharmacologic treatment (grade IIa); requirement for additional diagnostic or therapeutic procedures (grade IIb); lasting disability (grade III), or death (grade IV).

In total, 15,058 surgical procedures were performed in 8384 patients.

Of the patients admitted to the surgical ward during the study, 2033 (16.8%) had a complication and 735 (6.1%) had an error documented in the registry.

The incidence of error was highest for thoracic, vascular, and trauma surgery, with errors occurring in 9.9%, 9.2%, and 8.7% of patients, respectively. Furthermore, 10.5% of the 3737 patients who had a nonoperative treatment had at least one event registered.

Of all errors, 94.7% had no lasting effect on the patient (grade I, IIa, and IIb); however, almost a quarter of these required major additional interventions to counteract the effect of the error (grade IIb).

Drug errors included 23 errors in prescription and 24 in administration of medication. Errors in technique were the most frequent, with 188 (21.5%) errors occurring in total.

Errors that contributed to death included error in diagnosis, delay in diagnosis, error in judgment, error in technique, and delay to operating room for surgery.

Indeed, errors in technique were the most common cause of permanent injury (grade III) and re-operation (grade IIb), with 14.9% of the 188 errors resulting in grade III injuries and 60.6% resulting in re-operation.

Conversely, errors in hospital record and delay to operating room resulted in only minor consequences, with nearly 100% classified as grade I.

Writing in the British Journal of Surgery, the authors conclude:

"For many error types, the incidence of near misses by far outnumbers the incidence of errors that do have consequences?analysis of near misses may signal flaws in the healthcare provided well before serious injury occurs.

"Prospective registration of errors may improve quality of care when the database is evaluated regularly for patterns of errors to identify latent conditions and processes that may have contributed to errors."

MedWire (www.medwire-news.md ) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2011

By Ingrid Grasmo