An Observational Study of the Frequency, Severity, and Etiology of Failures in Postoperative Care After Major Elective General Surgery

Symons, Nicholas; Almoudaris, Alex M.; Nagpal, Kamal; Vincent, Charles; Moorthy, Krishna

doi:10.1097/sla.0b013e31826d859b

Cited by 57 publications

(51 citation statements)

References 22 publications

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“…(Alderman, 2012) Adverse events in surgical contexts (Healey et al, 2010) (Bohomol & Tartali, 2013) Adverse events in the continuity of care (Mistry et al, 2010) ( Kerckhoffs et al, 2013) Adverse events related with medication (Symons et al, 2013) (Cox & Butt, 2012) …”

Section: Resultsmentioning

confidence: 99%

“…A study made by several authors has proven, that about 75% of the adverse events could have been prevented, being the most common related with the prescription and administration of medicines, whose origin in 54% of cases relates to miscommunication (Symons, Almoudaris, Nagpal, Vincent, & Moorthy, 2013). Other authors pored up on the issue of errors and adverse events resulting from failures related to the medication, referring to the lack of openness in communication between professionals and generating errors related adverse drug reactions (Cox & Butt, 2012).…”

Section: Adverse Events Related To Medicationmentioning

confidence: 99%

See 1 more Smart Citation

Clinical Communication and Adverse Health Events: Literature Review

Ferreira¹,

Brás²,

Barbieri³

2016

European Proceedings of Social &Amp; Behavioural Sciences

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Health institutions have an increased risk of occurrence of errors due to their diversity, specificity and volume of services, representing a great concern for health professionals whose main function is to protect the health and lives of their patients. We intend to identify a body of evidence, that shows what the most common adverse events are and what adverse events potentially arise from clinical miscommunication. We made an integrative literature review using the keywords "Adverse Events", "Patient Safety", "Communication". An inquiry on databases of PubMed, Web of Science, Scielo and CINAHL, in articles published between January 2010 and March 2016, was made; all available in Portuguese and English. Of the 216 articles that emerged, we selected eight that answered the research questions: what are the most common adverse events that have their origin in communication errors? Analyzing the selected studies, it appears that the most common adverse events arise in the context of obstetrics and pediatrics, in surgical contexts, in the continuity of care and related medication. Patient safety should be seen as a key component of quality in health care, with good management of the risk of fundamental error for the promotion of this security. The knowledge and understanding that communication failures are one of the main factors contributing to the occurrence of errors in the context of health care, allows the subsequent development of strategies to improve this process and thus ensure safer healthcare.

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Section: Resultsmentioning

confidence: 99%

Section: Adverse Events Related To Medicationmentioning

confidence: 99%

Clinical Communication and Adverse Health Events: Literature Review

Ferreira¹,

Brás²,

Barbieri³

2016

European Proceedings of Social &Amp; Behavioural Sciences

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“…This is clearly benefi cial but, concomitantly, brings new risks. Errors in post-operative care and errors in non-operative management already cause more frequent adverse events than errors in surgical technique (Anderson et al 2013 ;Symons et al 2013 ). These trends will probably continue and even accelerate.…”

Section: New Challenges For Patient Safetymentioning

confidence: 99%

New Challenges for Patient Safety

Vincent

Amalberti

2016

Safer Healthcare

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The developments described in the previous chapters are required because our present vision of safety is not adequate for the challenges we face. Our arguments for these developments rest on analyses of the nature of safety in healthcare as it is delivered today. However, as is well known, healthcare is changing rapidly and there are many new opportunities, pressures and challenges. We believe that these coming changes will have further implications for how safety is understood and practiced which will increase the urgency and importance of the transition to a broader vision.In this chapter we briefl y summarise some of the recent and forthcoming developments in healthcare. These have been widely discussed and we are only concerned to summarise some key points. The primary purpose of the chapter is to consider the implications for patient safety and for the strategies and practices we set out in the remainder of the book. The Changing Nature of HealthcareThe problems faced by healthcare, and many of the challenges for patient safety, arise in part from the very success of modern medicine in combating disease. Because of improvements in diet, nutrition, medicine and environment many people are living longer but also living with one or more chronic conditions such as diabetes, cardiovascular disease and cancer. Diseases which were once fatal are now becoming chronic conditions.The survival rate for cancers, infections and AIDS, strokes, cardiovascular disease and many other previously fatal diseases have improved signifi cantly even in the last decade. For instance a recent French study of 427,000 new adult cancer cases diagnosed between 1989 and 2004, showed signifi cant improvements in 5 year survival for most cancers, especially prostate cancer (Grosclaude et al. 2013 ).In the French population of 65 million people over 320,000 new cancers are diagnosed every year; of these 150,000 are designated as 'cured' within the same 130 year and a further 150,000 can expect to survive at least 5 years. Similar improvements in survival and quality of life in AIDS patients have been seen in developed countries with the introduction of HAART therapies (Highly Active Antiretroviral Therapy) (Borrell et al. 2006 ). Most people treated for chronic conditions are going back to work, family and home, with the personal ambition of leading as healthy life as possible. These developments present huge challenges for healthcare systems in providing care and yet remaining affordable.The traditional hospital cannot remain the main provider of care and core of the medical system simply because it would be unaffordable. Hospitals are still of course essential in any future vision of healthcare but will increasingly focus on investigations and procedures that require a very high level of expertise and sophisticated technology. The proportion of beds devoted to high dependency and intensive care will increase while the overall number of beds will reduce (Ackroyd-Stolarz et al. 2011 ).Medical innovations have lead progressively to shorter h...

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“…Failures at various steps in patient journey could occur despite all efforts of the healthcare professionals. Process failures would cause serious injuries, increase the length of hospital stay and waste resources [4].…”

Section: Introductionmentioning

confidence: 99%

“…Since a single AE may have multiple causes, consequences and defensive barriers (preventability) in each phase of the healthcare procedures [9]. For example, clinical audit often assesses individual healthcare procedures, and as a result, fewer process failures is demonstrated regarding their frequency, relative risk, and cumulative effect on the surgical patient [4].The purpose of this study was to investigate the frequency and nature of failures in the healthcare procedures of the surgical patient journey for elective surgical patients. Additionally, final impacts and injuries, causes, preventability, and prevention strategies were also determined.…”

Section: Introductionmentioning

confidence: 99%

Research Paper: Risk Assessment of Surgical Procedures in a Referral Hospital

Rezaei

Yarmohammadian

Taleghani

et al. 2017

hdq

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Background: Adverse Events (AEs) due to failure in healthcare procedures are common. These procedures are often evaluated independently. The objectives of this study are to investigate the nature of the failures in healthcare procedures of the surgical patients, assessing the frequency of these failures and preventability, and exploring their consequences, underlying causes, and prevention strategies in a referral hospital in the center of Iran. Materials and Methods:This study is a prospective quantitative and qualitative research. Focus Group Discussion (FGD) meetings have been conducted to understand potential failures, their consequences, causes, and prevention strategies. Afterwards, the frequencies of these concepts have been determined separately in predefined subcategories in each step of the process. Results:The first phase of the patient care process was the most risk-prone phase. Temporary or permanent disability at the time of discharge (final impacts), inflammation/infection (injuries), the rule-based behavior associated with coordination (causes), information and communication, preventability more than 50 were the most frequent failures and had achieved the highest score. Conclusion:Failures of healthcare processes are preventable to a high degree, although patients injure frequently. Interventions to mitigate these failures will enhance the reliability of surgical procedures.

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An Observational Study of the Frequency, Severity, and Etiology of Failures in Postoperative Care After Major Elective General Surgery

Abstract: Process failures are common in postoperative care, are highly preventable, and frequently cause harm to patients. Interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce hospital stay.

Cited by 57 publications

References 22 publications

Clinical Communication and Adverse Health Events: Literature Review

Clinical Communication and Adverse Health Events: Literature Review

New Challenges for Patient Safety

Research Paper: Risk Assessment of Surgical Procedures in a Referral Hospital

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