A review of adverse event reporting in Irish surgical specialties

Abstract

Introduction Reporting of adverse events in medicine is an important concept. It is widely accepted that a key element of any healthcare service is the approach that is adopted towards reporting adverse events. Government legislation and the increased number of patient safety initiatives with widespread discussion within the medical literature marks adverse event reporting as an important topic for analysis. Methods The Clinical Indemnity Scheme (CIS) provides risk advisory services to state authorities in Ireland. This study will focus on 42,094 adverse events reported across all surgical specialties to the CIS via a confidential weblink (STARSWeb) since 2004. The most common features of each adverse event and closed medicolegal claims processed by the CIS were reviewed as part of this study. Results The majority of reported adverse events occur in orthopaedic and general surgery (73% of all cases). Slips/trips/falls are the most common adverse event reported. Doctors report only 4% of the total number of adverse events. The month of October records the highest number of adverse events with the highest frequency of adverse events taking place before 13:00 each day. The most common incident type which resulted in a claim being closed by the CIS was the perioperative/periprocedure incident (50% of all cases). Conclusions The CIS report a significant number of adverse events across a range of surgical specialties. A pattern of adverse events being reported during ‘daylight’ hours gives a clear indication that routine surgical operations and procedures carry with them a risk for injury to the patient. Particular months of the year and time of the day are more likely to be associated with reported adverse events. This pattern of events should be highlighted in an attempt to promote safer surgical practice within hospitals during particular times of the day, month or year.