Assessing, grading, and reporting intraoperative adverse events during and after surgery.

Abstract

Intraoperative adverse events (iAEs) are under-reported, have poorly standardized nomenclature, and are plagued by barriers to reporting and cultural acceptance. Not surprisingly, although surgeons are willing to report iAEs, they often under-report these events, especially those of lower severity, owing to perceived clinical insignificance1. Attempts to overcome reporting deficits with surgical black-box systems, otherwise known as medical data recorders, have continued to receive pushback despite the potential benefits for quality improvement2,3. Until these systems gain further traction, integration of iAE reporting into the sign-out portion of the WHO safety checklist might be a useful aide-memoire4,5. Barriers to reporting, such as institutional, emotional, and litigious concerns, remain challenging to overcome6. Further, the intransigent blame culture continues to detract from a universally shared goal of improved patient safety6. The, regrettably, common lack of institutional support for litigation concerns, and an absence of clear definitions of what should be reported and how to report, might be surmountable with improved awareness of available resources. There are several iAE classification systems available, including, but not limited to: Modified Satava, the iAE severity classification system (Massachusetts General Hospital), the European Association of Surgical Endoscopy classification7,8, intraoperative adverse incident classification (European Association of Urology)9, and the classification of intraoperative adverse events (ClassIntra®)10. These systems are universally available and can be used to clearly delineate what constitutes an iAE. However, with the exception of ClassIntra®, many of these systems have yet to be validated and are known to have high inter-rater variability10–13. In the absence of a single best system, a vital first step is to record and grade iAEs prospectively, regardless of which system is chosen, so that we can move on to understanding the real-world implications of iAEs. Although these classification systems are useful for grading iAEs, they stop short of providing guidelines for reporting in publications or daily practice.