Complications and deaths during surgery are typically discussed by clinicians at a weekly surgical morbidity and mortality conference, according to background information in the article. "Individual cases are typically presented by a resident, and a discussion ensues addressing the issues in that single case," the authors write. "Recent efforts have attempted to make the discussion more evidence-based and less blame-oriented. However, the focus has remained on individual cases, residents and physicians rather than on the system and overall quality of patient care."

In addition, the morbidity and mortality conference typically does not address near-misses, events that had the potential to result in an adverse outcome and can offer valuable learning opportunities. Karl Y. Bilimoria, M.D., M.S., of Feinberg School of Medicine, Northwestern University, Chicago and colleagues designed a Web-based system to track adverse and near-miss events and also established an automated method to identify patterns of these events. The system was implemented at a large metropolitan tertiary care center in September 2005. Residents entered data about adverse events used for the morbidity and mortality conference, and all clinicians in the surgery department were given a password to anonymously enter information about other adverse events and near misses.

Through August 2007, 15,524 surgical patients were reported including 957 (6.2 percent) adverse events and 34 (0.2 percent) anonymous reports. "The automated pattern recognition system helped identify four event patterns from morbidity and mortality reports and three patterns from anonymous/near-miss reporting," the authors write. "After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues and/or intensive quality monitoring." For instance, recurring errors in chest tube placements and nurse-to-physician communications were detected and managed.

The events entered into the online system also were compared with hospital databases to assess the completeness of reporting. Only 27.2 percent (264 of 970) of readmissions and 41.6 percent (89 of 214) of inpatient deaths were reported into the system; there was no change in monthly adverse reporting rate when the online system was initiated. "Though not surprising, this under-reporting was disappointing," the authors write. "During the study period, interventions aimed at increasing reporting had little effect." A presentation from the department chair regarding what constitutes an adverse event and the importance of tracking complications produced an initial spike in reporting that was short-lived.

"An electronic physician-reported event tracking system should be incorporated into all surgery departments irrespective of whether the department is associated with a residency program; however, this is just one component of what should be a larger quality improvement effort," the authors conclude. "An online event tracking system is a feasible, promising and potentially powerful initiative to improve surgical safety in the United States."

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Materials provided by JAMA and Archives Journals. Note: Content may be edited for style and length.

Journal Reference:

1. Karl Y. Bilimoria, MD, MS; Thomas E. Kmiecik, PhD; Debra A. DaRosa, PhD; Amy Halverson, MD; Mark K. Eskandari, MD; Richard H. Bell Jr, MD; Nathaniel J. Soper, MD; Jeffrey D. Wayne, MD. Development of an Online Morbidity, Mortality, and Near-Miss Reporting System to Identify Patterns of Adverse Events in Surgical Patients. Arch Surg., 2009;144(4):305-311 [abstract]