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Evaluation and Outcome of Surgeon-Reported Incidents regarding Surgical Patient Safety

Surgical safety has emerged as a crucial health issue in the past two decades, requiring increased financial and research investments. In this paper, the authors retrospectively analyzed incident reports from surgeons to learn about surgical patient safety and improve surgical quality. 

For the 10 years and 3 months between February 2007 and May 2017, 236 incident reports from surgeons were collected. The impact levels of the incidents for patients were represented by a degree of adverse influence to a patient (level 0, 1, 2, 3a, 3b, 4a, 4b, and 5). The outcome of the incident reports was evaluated by the profile, cause, surgery-relation, and factor. The data in this study were analyzed by breakdown of the stratified analysis, distribution of numbers, and ratio.

The level of incidents resulted in level 0 (n = 18, 7.6%), level 1 (n = 28, 11.9%), level 2 (n = 16, 6.8%), level 3a (n = 44, 18.6%), level 3b (n = 94, 39.8%), level 4a (n = 1, 0.4%), level 4b (n = 6, 2.5%), level 5 (n = 15, 6.4%) and others (n = 14, 5.9%). The profiles of the surgery-related incidents (n = 84) showed other unexpected events (15.7%, n = 37), second surgery within 24 hours (9.3%, n = 22), and unexpected excessive bleeding (6.8%, n = 16). The cause of the sur-gery-related incidents involved hemorrhage (n = 45, 53.6%). Except for complications and accidental diseases (n = 77, 32.6%), the occurrence factor of the incidents cited factors of personal behavior (n = 85, 36.0%), human factors (n = 37, 15.7%), environmental equipment (n = 6, 2.5%), and others (n = 31, 13.1%). 

In conclusion, for surgeons, it becomes a very useful tool to submit incident reports, because the surgeons can retrospectively review a novel surgical experience by analyzing the surgical incidents and can improve their surgical quality. Also, it is important for a surgeon to properly understand and implement patient safety behavior and to have an appropriate open disclosure attitude. Furthermore, an aggressive reporting atmosphere and high-level patient safety system should be developed, and the breeding of a good safety culture will become important.


Article by Takanori Ayabe, et al, from Japan.


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