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2017 HSR&D/QUERI National Conference Abstract

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1008 — Capturing Intraoperative Adverse Events (IAEs) By Surgical Debriefing: Does It Complement the IAE Detection By Traditional Incident Reporting?

Lead/Presenter: Qi Chen, COIN - Bedford/Boston
All Authors: Chen Q (Center for Healthcare Organization and Implementation Research (CHOIR)) Rochman A (Center for Healthcare Organization and Implementation Research (CHOIR)) Amirfarzan H (VA Boston Healthcare System) Itani K (VA Boston Healthcare System) Rosen A (Center for Healthcare Organization and Implementation Research (CHOIR))

Patient safety has become a national concern since the 1999 Institute of Medicine report. Despite various efforts on tracking adverse events, little is known about events that occur during surgery, i.e., intraoperative adverse events (IAEs). As a commonly used method to track adverse events in clinical practice, incident reporting system is implemented among nation-wide Veterans Health Administration (VA) hospitals. Although it is not specifically designed for surgical care, as part of a surgical quality improvement effort at our facility, staff are encouraged to use incident reporting system to report adverse events that occur during operation, i.e., intraoperative adverse events (IAEs). In addition to incident reporting, our facility also has a program to ask surgeons, anesthesiologists, and nurses to report IAEs during surgical debriefing right after each operation. This study aims to examine the IAEs collected by surgical debriefing and incident reporting in order to assess whether surgical debriefing may complement the IAE detection by the traditional incident reporting system.

We constructed a database consisting of the IAEs captured by both surgical debriefing and incident reporting at our facility between 12/1/2015-11/30/2016. We examined the types and rates of IAEs detected by each method, and explored whether there was any overlap of events between the two methods.

There were a total of 3020 surgical procedures performed during the study period, with 279 IAEs detected, yielding an overall IAE detection rate of 9%. Among the 279 IAEs, 136 (49%) and 143 (51%) IAEs were captured by surgical debriefing and incident reporting, respectively; only 4 (1%) IAEs were detected by both methods. The most frequent IAEs detected from surgical debriefing included hypotension (n = 25, 18%), bradycardia (n = 22, 16%), hypothermia (n = 15, 11%) and unplanned ICU admission (n = 15, 11%). On the contrary, the most frequent IAEs detected from incident reporting were more likely to be system-related issues than patient harms. For example, there were 40 (28%) device failures, e.g., broken operation bed, broken needle, device misfire, etc.; 18 (13%) incorrect instrument counts; 18 (13%) cases with either incorrect or missing label on specimen; 16 (11%) cases that had device unavailable at the time of operation, and 9 (6%) communication issues, i.e., unable to reach needed staff due to not-working beeper or undocumented cell phone. The 4 overlapped IAEs between surgical debriefing and incident reporting included 2 events of allergy to device, 1 medication error, and 1 event of unawareness of prior implant history.

Surgical debriefing captures different IAEs than incident reporting. This suggests that surgical debriefing may complement the IAE detection that is usually tracked by incident reporting.

To improve our knowledge of patient safety, efforts are needed to systematically capture IAEs. Hospitals should consider adopting both methods, i.e., surgical debriefing and incident reporting, in order to obtain a complete picture of intraoperative patient safety. Future effort is needed to examine the association between these IAEs and postoperative patient outcomes.