An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery

Annals of Surgery

Volumn 257, Issue 1, 2013, Pages 1-5

  Symons, Nicholas R A ^a   Almoudaris, Alex M ^a   Nagpal, Kamal ^a   Vincent, Charles A ^a   Moorthy, Krishna ^a  

^a IMPERIAL COLLEGE LONDON   (United Kingdom)

Author keywords

Adverse event; observation; postoperative care; process assessment; process failure; surgery

Indexed keywords

ADULT; AGED; ARTICLE; CLINICAL ARTICLE; DISEASE SEVERITY; ELECTIVE SURGERY; FEMALE; GASTROINTESTINAL SURGERY; GENERAL SURGERY; HOSPITAL MANAGEMENT; HUMAN; MALE; MEDICATION THERAPY MANAGEMENT; OBSERVATIONAL STUDY; PAIN ASSESSMENT; POSTOPERATIVE CARE; POSTOPERATIVE PAIN; PRESCRIPTION; PRIORITY JOURNAL; PROSPECTIVE STUDY; SURGICAL RISK; TREATMENT FAILURE;

ADULT; AGED; AGED, 80 AND OVER; DIGESTIVE SYSTEM SURGICAL PROCEDURES; FEMALE; GENERAL SURGERY; HOSPITALS, TEACHING; HOSPITALS, URBAN; HUMANS; INTERPROFESSIONAL RELATIONS; LONDON; MALE; MEDICAL ERRORS; MIDDLE AGED; OUTCOME AND PROCESS ASSESSMENT (HEALTH CARE); PATIENT SAFETY; POSTOPERATIVE CARE; PROSPECTIVE STUDIES; SURGICAL PROCEDURES, ELECTIVE;

EID: 84871545848     PISSN: 00034932     EISSN: 15281140     Source Type: Journal    
DOI: 10.1097/SLA.0b013e31826d859b     Document Type: Article

References (26)

1. Leape LL. Error in medicine. JAMA. 1994;272:1851-1857. (Pubitemid 24374526)
2. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit Crit Care Med. 1995;23:294-300.
3. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376.
4. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med JAust. 1995;163:458-471.
5. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminaryretrospective recordreview. BMJ. 2001;322:517-519. (Pubitemid 32230913)
6. Nagpal K, Vats A, Ahmed K, et al. An evaluation of information trans-fer through the continuum of surgical care: a feasibility study. Ann Surg. 2010;252:402-407.
7. Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review. Ann Surg. 2010;252:225-239.
8. Kohn L, Corrigan J, Donaldson ME. To Err Is Human. Washington, DC: National Academy Press; 1999.
9. De Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17:216-223.
10. Vincent C, Moorthy K, Sarker SK, et al. Systemsapproachestosurgicalquality and safety: from concept to measurement. Ann Surg. 2004;239:475-482.
11. Birkmeyer JD, Dimick JB, Birkmeyer NJ. Measuring the quality ofsurgical care: structure, process, or outcomes?JAm Coll Surg. 2004;198:626-632.
12. Lilford RJ, Brown CA, Nicholl J. Use ofprocess measures to monitor the quality ofclinical practice. BMJ. 2007;335:648-650. (Pubitemid 47548455)
13. Weinger MB, Slagle J. Human factors research in anesthesia patient safety: techniques to elucidate factors affecting clinical task performance and decision making. JAm Med Inform Assoc. 2002;9:S58-S63.
14. Schraagen JM, Schouten T, Smit M, et al. A prospective study of paedi-atric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. BMJ Qual Saf. 2011;20:599-603.
15. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of ad-verse events and negligent care in Utah and Colorado. Med Care. 2000;38: 261-271.
16. Shrout PE, Fleiss JL. Intraclass correlations\-uses in assessing rater reliability. Psychol Bull. 1979;86:420-428.
17. Reason JT. Human Error. New York: Cambridge University Press; 1990.
18. Stevenson KS, Gibson SC, Mac Donald D, et al. Measurement ofprocess as quality control in the management of acute surgical emergencies. Br J Surg. 2007;94:376-381. (Pubitemid 46423858)
19. Kreckler S, Catchpole KR, New SJ, et al. Quality and safety on an acute surgical ward: an exploratory cohort study ofprocess and outcome. Ann Surg. 2009;250:1035-1040.
20. Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events inmedical care. Lancet. 1997;349:309-313. (Pubitemid 27056822)
21. Needham DM, Sinopoli DJ, Thompson DA, et al. A system factors analysis of "line, tube, and drain" incidents in the intensive care unit. Crit Care Med. 2005;33:1701-1707.
22. Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICUusing dailygoals. J Crit Care. 2003;18:71-75.
23. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:1693-1700.
24. Lilford R, Edwards A, Girling A, et al. Inter-rater reliability ofcase-note audit: a systematic review. JHealth Serv Res Policy. 2007;12:173-180. (Pubitemid 47122233)
25. Dr Foster Research Limited. Dr Foster Report Card2010. Available at: http:// www.drfosterhealth.co.uk/quality-reports/default.aspx. Accessed September 17, 2011.
26. Donabedian A. Evaluating the quality ofmedical care. Milbank Mem Fund Q. 1966;44:166-206.