Learning from Adverse Events and Near Misses

Abstract

Patient safety has received increasing attention since the Institute of Medicine (IOM) published To Err is Human suggesting that 3–4% of hospitalized patients will experience an adverse event. In looking closer at the etiology of these events, it is obvious that, as surgeons, we can play a major role in improving patient safety. Over half of all medical adverse events are surgical in nature and 75% of these occur in the operating room (OR). It therefore seems that the greatest improvements in patient safety will be achieved by targeting the OR for safety research and intervention. The predominance of operative adverse events is not surprising. Not only is the OR the site of the most invasive type of medical care, it is also one of the most complex work environments in which people perform. Yet, despite a large body of literature addressing safety and coordination in other complex work environments, limited research on the OR exists.