Three Never Complications of Surgery Are Hardly That

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Three "Never Complications of Surgery"
Are Hardly That

PA PSRS Patient Saf Advis 2007 Sep;4(3):82.

PA-PSRS has previously reported on three complications of surgery that should never be considered risks that the patient must accept when undergoing an operation: unintentionally leaving something behind (retained foreign body; see “Tips from PA Facilities: Enforcing the Time Out and Preventing Retained Foreign Bodies” in the June 2005 PA-PSRS Patient Safety Advisory), operating on the wrong site (wrong-site surgery; see “Doing the ‘Right’ Things to Correct Wrong-Site Surgery” in the June 2007 Advisory), and setting the patient on fire (surgical fire; see articles in the March 2007, December 2006, and September 2007 issues of the Advisory). During separate analyses of these three complications, PA-PSRS has determined the number of reports of each during the time periods of analysis for each project. Based on reports from the Pennsylvania Department of Health of 2,424,879 total operations in 2005 in Pennsylvania hospitals and ambulatory surgery centers,^{1, 2} PA-PSRS analysts calculated the chances of a patient experiencing a complication that should never be a risk that the patient must accept (see Table).

Table. Risk of Three "Never Complications of Surgery"

Although these “never complications of surgery” should never occur, more than 100 patients are currently anticipated to experience them every year. A reasonable goal is zero.

Notes

Pennsylvania Department of Health Bureau of Health Statistics and Research. Selected data from the annual hospital questionnaire reporting period July 1, 2004 through June 30, 2005 (Report 11-A): utilization of operating rooms in general acute care hospitals [online]. [cited 2007 Aug 6]. Available from Internet: http://www.dsf.health.state.
pa.us/health/lib/health/facilities/hosamb/2004-2005/REP11A.pdf.
Pennsylvania Department of Health Bureau of Health Statistics and Research. Data from the annual ambulatory surgery center questionnaire reporting period July 1, 2004 through June 30, 2005 (report 1): utilization and services by facility and county [online]. [cited 2006 Aug 7]. Available from Internet: http://www.dsf.health.state.pa.us/health/
lib/health/facilities/hosamb/2004-2005/ASCREP120042005.pdf.

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Three "Never Complications of Surgery" Are Hardly That
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	THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS
	The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .
	ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.
	The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.