Understanding ultrarare adverse events - Lessons learned from a twelve-year review of intraoperative deaths at an academic medical center

• Published in: The American journal of surgery Vol. 226; no. 3; pp. 315 - 321
• Main Authors: Cohen, Tara N., Kanji, Falisha F., Wang, Andrew S., Seferian, Edward G., Sax, Harry C., Gewertz, Bruce L.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.09.2023; Elsevier Limited
• Subjects: Adverse events; Communication; Demographics; Elective surgery; Emergency medical care; Emergency procedures; Environmental factors; Ergonomics; Fatalities; Health care facilities; Heart surgery; Human factors; Internal medicine; Intraoperative death; Medicine; Patient safety; Retrospective review; Surgeons; Transplants & implants; Trauma; Variables; Intraoperative death; Patient safety; Retrospective review; Ergonomics; Adverse events; Human factors
• ISSN: 0002-9610; 1879-1883
• DOI: 10.1016/j.amjsurg.2023.05.013

Intraoperative death (ID) is rare, the incidence remains challenging to quantify and learning opportunities are limited. We aimed to better define the demographics of ID by reviewing the longest single-site series. Retrospective chart reviews, including a review of contemporaneous incident reports, were performed on all ID between March 2010 to August 2022 at an academic medical center. Over 12 years, 154 IDs occurred (∼13/year, average age: 54.3 years, male: 60%). Most occurred during emergency procedures (n = 115, 74.7%), 39 (25.3%) during elective procedures. Incident reports were submitted in 129 cases (84%). 21 (16.3%) reports cited 28 contributing factors including challenges with coordination (n = 8, 28.6%), skill-based errors (n = 7, 25.0%), and environmental factors (n = 3, 10.7%). Most deaths occurred in patients admitted from the ER with general surgical problems. Despite expectations for incident reporting, few provided actionable information on ergonomic factors which might help identify improvement opportunities. [Display omitted] •About 13 intraoperative deaths occurred per year over 12 years.•Most intraoperative deaths occur during emergency procedures.•Incident reports rarely cite ergonomic opportunities for improvement.