Volume 3, Issue 1 (Autumn 2017)                   hdq 2017, 3(1): 21-30 | Back to browse issues page
1- Department of Health in Disasters and Emergencies, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran.
2- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran.
3- PhD Candidate Student Research Committee, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
Abstract:   (232 Views)
Background: Adverse Events (AEs) due to failure in healthcare procedures are common. These procedures are often evaluated independently. The objectives of this study are to investigate the nature of the failures in healthcare procedures of the surgical patients, assessing the frequency of these failures and preventability, and exploring their consequences, underlying causes, and prevention strategies in a referral hospital in the center of Iran.
Materials and Methods: This study is a prospective quantitative and qualitative research. Focus Group Discussion (FGD) meetings have been conducted to understand potential failures, their consequences, causes, and prevention strategies. Afterwards, the frequencies of these concepts have been determined separately in predefined subcategories in each step of the process.
Results: The first phase of the patient care process was the most risk-prone phase. Temporary or permanent disability at the time of discharge (final impacts), inflammation/infection (injuries), the rule-based behavior associated with coordination (causes), information and communication, preventability more than 50 were the most frequent failures and had achieved the highest score.
Conclusion: Failures of healthcare processes are preventable to a high degree, although patients injure frequently. Interventions to mitigate these failures will enhance the reliability of surgical procedures.
Full-Text [PDF 828 kb]   (67 Downloads) |   |   Full-Text (HTML)  (19 Views)  
Type of Study: Research | Subject: Special
Received: 2017/06/2 | Accepted: 2017/09/15 | Published: 2017/10/1

1. Johnston M, Arora S, Anderson O, King D, Behar N, Darzi A. Escalation of care in surgery. Annals of Surgery. 2015; 261(5):831–8. doi: 10.1097/sla.0000000000000762 [DOI:10.1097/SLA.0000000000000762]
2. Donchin Y. A look into the nature and causes of human errors in the intensive care unit. Quality and Safety in Health Care. 2003; 12(2):143–7. doi: 10.1136/qhc.12.2.143 [DOI:10.1136/qhc.12.2.143]
3. Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. An evaluation of information transfer through the continuum of surgical care. Annals of Surgery. 2010; 252(2):402–7. doi: 10.1097/sla.0b013e3181e986df [DOI:10.1097/SLA.0b013e3181e986df]
4. Symons NRA, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. Annals of Surgery. 2013; 257(1):1–5. doi: 10.1097/sla.0b013e31826d859b [DOI:10.1097/SLA.0b013e31826d859b]
5. De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: A systematic review. Quality and Safety in Health Care. 2008; 17(3):216–23. doi: 10.1136/qshc.2007.023622 [DOI:10.1136/qshc.2007.023622]
6. Sukumar S, Roghmann F, Trinh VQ, Sammon JD, Gervais M-K, Tan HJ, et al. National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. BMJ Open. 2013; 3(6):e002843. doi: 10.1136/bmjopen-2013-002843 [DOI:10.1136/bmjopen-2013-002843]
7. Agency for Healthcare Research and Quality. Patient safety indicators overview. Rockville: Agency for Healthcare Research and Quality; 2017.
8. Anderson O, Davis R, Hanna GB, Vincent CA. Surgical adverse events: A systematic review. The American Journal of Surgery. 2013; 206(2):253–62. doi: 10.1016/j.amjsurg.2012.11.009 [DOI:10.1016/j.amjsurg.2012.11.009]
9. Yarmohammadian M, Ferdosi M, Haghshenas A, Rezaei F. Developing an integrated clinical risk management model for Hospitals. International Journal of Health System and Disaster Management. 2013; 1(4):221. doi: 10.4103/2347-9019.130740 [DOI:10.4103/2347-9019.130740]
10. Molavi Taleghani Y, Seyedin H, Vafaee Najar A, Ebrahimipour H, Pourtaleb A. Risk assessment of drug management process in women surgery department of Qaem Educational Hospital (QEH) using HFMEA method (2013). Iranian Journal of Pharmaceutical Research. 2015; 14(2):495-504. PMCID: PMC4403066
11. Van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Nature, causes and consequences of unintended events in surgical units. British Journal of Surgery. 2010; 97(11):1730–40. doi: 10.1002/bjs.7201 [DOI:10.1002/bjs.7201]
12. Michel P. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ. 2004; 328(7433):199–0. doi: 10.1136/bmj.328.7433.199 [DOI:10.1136/bmj.328.7433.199]
13. Aranaz Andres JM, Aibar Remon C, Vitaller Burillo J, Requena Puche J, Terol Garcia E, Kelley E, et al. Impact and preventability of adverse events in Spanish public hospitals: Results of the Spanish National Study of Adverse Events (ENEAS). International Journal for Quality in Health Care. 2009; 21(6):408–14. doi: 10.1093/intqhc/mzp047 [DOI:10.1093/intqhc/mzp047]
14. Rezaei F, Yarmohammadian M, Ferdosi M, Haghshenas A. Principles of risk management in surgery departments. Archives of Clinical and Experimental Surgery (ACES). 2015; 4(3):126. doi: 10.5455/aces.20140925015830 [DOI:10.5455/aces.20140925015830]
15. Zegers M, de Bruijne MC, de Keizer B, Merten H, Groenewegen PP, van der Wal G, et al. The incidence, roo causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies. Patient Safety in Surgery. 2011; 5(1):13. doi: 10.1186/1754-9493-5-13 [DOI:10.1186/1754-9493-5-13]
16. World Health Organization. The conceptual framework for the international classification for patient safety (v.1.1): Final technical report and technical annexes. New York: World Health Organization; 2010.
17. Van Vuuren W, Shea CE, van der Schaaf TW, Technische hogeschool (Eindhoven, Pays Bas). The development of an incident analysis tool for the medical field. Eindhoven: Eindhoven University of Technology; 1997.
18. Zegers M, de Bruijne MC, Wagner C, Groenewegen PP, Waaijman R, van der Wal G. Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch hospitals. BMC Health Services Research. 2007; 7(1). Doi: 10.1186/1472-6963-7-27 [DOI:10.1186/1472-6963-7-27]
19. Merten H, Johannesma PC, Lubberding S, Zegers M, Langelaan M, Jukema GN, et al. High risk of adverse events in hospitalised hip fracture patients of 65 years and older: Results of a retrospective record review study. BMJ Open. 2015; 5(9):e006663. doi: 10.1136/bmjopen-2014-006663 [DOI:10.1136/bmjopen-2014-006663]
20. Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. International Journal for Quality in Health Care. 2002; 14(4):269–76. doi: 10.1093/intqhc/14.4.269 [DOI:10.1093/intqhc/14.4.269]
21. Marquet K, Claes N, De Troy E, Kox G, Droogmans M, Schrooten W, et al. One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event. Critical Care Medicine. 2015; 43(5):1053–61. doi: 10.1097/ccm.0000000000000932 [DOI:10.1097/CCM.0000000000000932]
22. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model. Annals of Surgery. 2013; 257(5):867–72. doi: 10.1097/sla.0b013e31826fccfa [DOI:10.1097/SLA.0b013e31826fccfa]
23. Vincent C. Adverse events in British hospitals: Preliminary retrospective record review. BMJ. 2001; 322(7285):517–9. doi: 10.1136/bmj.322.7285.517 [DOI:10.1136/bmj.322.7285.517]
24. Vlayen A, Verelst S, Bekkering GE, Schrooten W, Hellings J, Claes N. Incidence and preventability of adverse events requiring intensive care admission: A systematic review. Journal of Evaluation in Clinical Practice. 2011; 18(2):485–97. doi: 10.1111/j.1365-2753.2010.01612.x [DOI:10.1111/j.1365-2753.2010.01612.x]
25. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine. 2009; 360(5):491–9. doi: 10.1056/nejmsa0810119 [DOI:10.1056/NEJMsa0810119]
26. Mahajan RP. The WHO surgical checklist. Best Practice & Research Clinical Anaesthesiology. 2011; 25(2):161–8. doi: 10.1016/j.bpa.2011.02.002 [DOI:10.1016/j.bpa.2011.02.002]
27. De Vries EN, Hollmann MW, Smorenburg SM, Gouma DJ, Boermeester MA. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Quality and Safety in Health Care. 2009; 18(2):121–6. doi: 10.1136/qshc.2008.027524 [DOI:10.1136/qshc.2008.027524]
28. De Vries EN, Prins HA, Bennink MC, Neijenhuis P, van Stijn I, van Helden SH, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Quality & Safety. 2012; 21(6):503–8. doi: 10.1136/bmjqs-2011-000347 [DOI:10.1136/bmjqs-2011-000347]
29. Calland JF, Adams RB, Benjamin DK, O'Connor MJ, Chandrasekhara V, Guerlain S, et al. Thirty day postoperative death rate at an academic medical center. Annals of Surgery. 2002; 235(5):690–8. doi: 10.1097/00000658-200205000-00011 [DOI:10.1097/00000658-200205000-00011]
30. Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. Journal of the Royal Society of Medicine. 2001; 94(7):322-30. [DOI:10.1177/014107680109400702]
31. Linden AF, Sekidde FS, Galukande M, Knowlton LM, Chackungal S, McQueen KAK. Challenges of surgery in developing countries: A survey of surgical and anesthesia capacity in Uganda's public hospitals. World Journal of Surgery. 2012; 36(5):1056–65. doi: 10.1007/s00268-012-1482-7 [DOI:10.1007/s00268-012-1482-7]
32. Dunn KL. Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: Detection of adverse events and insight into the system. Archives of Disease in Childhood. 2005; 91(2):169–72. doi: 10.1136/adc.2005.074179 [DOI:10.1136/adc.2005.074179]