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.
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