Adverse Events in General Surgery. A Prospective Analysis of 13 950 Consecutive Patients

Abstract

IntroductionAdverse event (AE) rates in general surgery vary, according to different authors and recording methods, between 2% and 30%. Six years ago we designed a prospective AE recording system to change patient safety culture in our department. We present the results of this work after a 6-year follow-up. Material and methodThe AE, sequelae and health care errors in a University Hospital surgery department were recorded. An analysis of each incident recorded was performed by a reviewer. The data were entered into database for rapid access and consultation. The results were routinely presented in departmental morbidity–mortality sessions. ResultsA total of 13950 patients had suffered 11254 AE, which affected 5142 of them (36.9% of admissions). A total of 920 patients were subjected to at least one health care error (6.6% of admissions). This meant that 6.6% of our patients suffered an avoidable AE. The overall mortality at 5 years in our department was 2.72% (380 deaths). An adverse event was implicated in the death of the patient in 180 cases (1.29% of admissions). In 49 cases (0.35% of admissions), mortality could be attributed to an avoidable AE. After 6 years there tends to be an increasingly lower incidence of errors. ConclusionsThe exhaustive and prospective recording of AE leads to changes in patient safety culture in a surgery department and helps decrease the incidence of health care errors.