Elsevier

Surgery

Volume 126, Issue 1, July 1999, Pages 66-75
Surgery

Surgical Outcomes Research
The incidence and nature of surgical adverse events in Colorado and Utah in 1992ast;,**

https://doi.org/10.1067/msy.1999.98664Get rights and content

Abstract

Background: Despite more than three decades of research on iatrogenesis, surgical adverse events have not been subjected to detailed study to identify their characteristics. This information could be invaluable, however, for guiding quality assurance and research efforts aimed at reducing the occurrence of surgical adverse events. Thus we conducted a retrospective chart review of 15,000 randomly selected admissions to Colorado and Utah hospitals during 1992 to identify and analyze these events. Methods: We selected a representative sample of hospitals from Utah and Colorado and then randomly sampled 15,000 nonpsychiatric discharges from 1992. With use of a 2-stage record-review process modeled on previous adverse event studies, we estimated the incidence, morbidity, and preventability of surgical adverse events that caused death, disability at the time of discharge, or prolonged hospital stay. We characterized their distribution by type of injury and by physician specialty and determined incidence rates by procedure. Results: Adverse events were no more likely in surgical care than in nonsurgical care. Nonetheless, 66% of all adverse events were surgical, and the annual incidence among hospitalized patients who underwent an operation or child delivery was 3.0% (confidence interval 2.7% to 3.4%). Among surgical adverse events 54% (confidence interval 48.9% to 58.9%) were preventable. We identified 12 common operations with significantly elevated adverse event incidence rates that ranged from 4.4% for hysterectomy (confidence interval 2.9% to 6.8%) to 18.9% for abdominal aortic aneurysm repair (confidence interval 8.3% to 37.5%). Eight operations also carried a significantly higher risk of a preventable adverse event: lower extremity bypass graft (11.0%), abdominal aortic aneurysm repair (8.1%), colon resection (5.9%), coronary artery bypass graft/cardiac valve surgery (4.7%), transurethral resection of the prostate or of a bladder tumor (3.9%), cholecystectomy (3.0%), hysterectomy (2.8%), and appendectomy (1.5%). Among all surgical adverse events, 5.6% (confidence interval 3.7% to 8.3%) resulted in death, accounting for 12.2% (confidence interval 6.9% to 21.4%) of all hospital deaths in Utah and Colorado. Technique-related complications, wound infections, and postoperative bleeding produced nearly half of all surgical adverse events. Conclusion: These findings provide direction for research to identify the causes of surgical adverse events and for targeted quality improvement efforts. (Surgery 1999;126:66-75.)

Section snippets

Methods

We sought to provide a detailed analysis of surgical adverse events through a retrospective chart review of 15,000 randomly selected admissions to Colorado and Utah hospitals during 1992 with use of the techniques of previous adverse event studies.20 Specifically, in addition to estimating the incidence, morbidity, and preventability of surgical adverse events, we sought to characterize their distribution by type of injury and by physician specialty and to determine incidence rates by

Patient characteristics

We completed initial review of 14,700 of 15,000 records (98.0%) in the original random sample. Patients were 38.9 years old on average in our sample compared with 38.2 years for all discharges, women were 61% of our sample and 59% of all discharges, Medicare beneficiaries were 24% of both groups, Medicaid beneficiaries were 15% of both groups, the privately insured were 47% of our sample and 46% of all discharges, managed care enrollees were 8% versus 11%, and the uninsured were 6% versus 5%.

Discussion

Contrary to a perhaps-common perception, our study of hospitalized patients in Colorado and Utah in 1992 found that adverse events resulting in death, disability, or a prolonged hospital stay were no more likely to occur in surgical care than in nonsurgical care. Overall, such adverse events occurred in approximately 3% of admissions in the 2 states in 1992. How much the incidence of adverse events varies by region is unknown, but this could represent a decline from previous incidence rates of

Acknowledgements

We thank Dr John Orav for his advice on statistical analysis and Drs Lucian Leape and Jennifer Daley for their advice on preparing the manuscript.

References (55)

  • LL Leape et al.

    The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II

    N Engl J Med

    (1991)
  • DC Classen et al.

    Computerized surveillance of adverse drug events in hospital patients

    JAMA

    (1991)
  • LL Leape et al.

    Systems analysis of adverse drug events

    JAMA

    (1995)
  • DC Classen et al.

    Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality

    JAMA

    (1997)
  • DW Bates et al.

    Effect of computerized physician order entry and a team intervention on prevention of serious medication errors

    JAMA

    (1998)
  • JM Overhage et al.

    A randomized trial of “corollary orders” to prevent errors of omission

    J Am Med Inform Assoc

    (1997)
  • RS Evans et al.

    A computer-assisted management program for antibiotics and other antiinfective agents

    N Engl J Med

    (1998)
  • EC. Pierce

    The 34th Rovenstine lecture; 40 years behind the mask: safety revisited

    Anesthesiology

    (1996)
  • NP Couch et al.

    The high cost of low-frequency events: the anatomy and economics of surgical mishaps

    N Engl J Med

    (1981)
  • C. Bosk

    Forgive and remember: managing medical failure

  • EA Campling et al.

    Report of the National Confidential Enquiry into Perioperative Deaths, 1990

    (1992)
  • JN. Lunn

    The National Confidential Enquiry into Perioperative Deaths

    J Clin Monit

    (1994)
  • L Feldman et al.

    Measuring postoperative complications in general surgery patients using an outcomes-based strategy: comparison with complications presented at morbidity and mortality rounds

    Surgery

    (1997)
  • TA Brennan et al.

    Identification of adverse events occurring during hospitalization: a cross-sectional study of litigation, quality assurance, and medical records at two teaching hospitals

    Ann Intern Med

    (1990)
  • HH Hiatt et al.

    A study of medical injury and medical malpractice: an overview

    N Engl J Med

    (1989)
  • Reference deleted in...
  • US Department of Health et al.

    ICD-9-CM: international classification of diseases, clinical modification

    (1989)
  • Cited by (755)

    • Report forms: Harm and quality of life

      2023, Translational Interventional Radiology
    • The scope and prevalence of perioperative harm

      2023, Handbook of Perioperative and Procedural Patient Safety
    View all citing articles on Scopus
    ast;

    Supported by the Robert Wood Johnson Foundation, Princeton, NJ. A. A. G. is supported by an Agency for Health Care Policy and Research postdoctoral fellowship award.

    **

    Reprint requests: Atul A. Gawande, MD, Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.

    View full text