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Are you ready to respond?: reports of high harm complications after surgery and invasive procedures

Series Title(s):
Pennsylvania patient safety advisory
Author(s):
Magee, Mary C., author
Finley, Edward, author
Liberatore, Kim, author
Contributor(s):
Pennsylvania. Patient Safety Authority, issuing body.
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, December 2018
Language(s):
English
Format:
Text
Subject(s):
Clinical Deterioration
Failure to Rescue, Health Care -- statistics & numerical data
Intraoperative Complications -- mortality
Intraoperative Complications -- prevention & control
Postoperative Complications -- mortality
Postoperative Complications -- prevention & control
Surgical Procedures, Operative -- adverse effect
Surgical Procedures, Operative -- mortality
Anatomy
Blood Loss, Surgical
Blood Transfusion
Hospital Rapid Response Team
Medical Errors -- prevention & control
Patient Safety
Resuscitation -- methods
Treatment Outcome
Humans
Pennsylvania
United States
Genre(s):
Technical Report
Abstract:
Surgery and other invasive procedures carry risk of complication and mortality. Recognizing and responding rapidly to such complications can improve patient outcomes. The Pennsylvania Patient Safety Authority sought to explore surgical complications and healthcare providers' responses by analyzing events reported as complications after surgery that resulted in permanent harm, near death, or death outcomes (high harm events). Analysts queried the Pennsylvania Patient Safety Reporting System for these high harm events submitted under the "complication following surgery or invasive procedure" event subtype for the 2017 academic year (i.e., 12 months ended June 2018). The query yielded 129 events of which cardiovascular and gastrointestinal procedures predominated (59.7%, n = 77 of 129). In these categories, bleeding and puncture, laceration, or tear were the most common complications (73.6%, n = 95 of 129). The majority of these high harm events (85.3%, n = 110 of 129) described some type of patient symptomatology to which healthcare providers responded 90.7% (n = 117 of 129) of the time. The majority of events resulted in death (65.1%, n = 84 of 129). Healthcare facilities can act now by using a similar analysis on their own cases and evaluate complication-response mechanisms to identify priorities for surgical-care learning and improvement.
Copyright:
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
Extent:
1 online resource (1 PDF file (17 pages))
Illustrations:
Illustrations
NLM Unique ID:
101739379 (See catalog record)
Series Title(s):
Pennsylvania patient safety advisory
Author(s):
Magee, Mary C., author
Finley, Edward, author
Liberatore, Kim, author
Contributor(s):
Pennsylvania. Patient Safety Authority, issuing body.
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, December 2018
Language(s):
English
Format:
Text
Subject(s):
Clinical Deterioration
Failure to Rescue, Health Care -- statistics & numerical data
Intraoperative Complications -- mortality
Intraoperative Complications -- prevention & control
Postoperative Complications -- mortality
Postoperative Complications -- prevention & control
Surgical Procedures, Operative -- adverse effect
Surgical Procedures, Operative -- mortality
Anatomy
Blood Loss, Surgical
Blood Transfusion
Hospital Rapid Response Team
Medical Errors -- prevention & control
Patient Safety
Resuscitation -- methods
Treatment Outcome
Humans
Pennsylvania
United States
Genre(s):
Technical Report
Abstract:
Surgery and other invasive procedures carry risk of complication and mortality. Recognizing and responding rapidly to such complications can improve patient outcomes. The Pennsylvania Patient Safety Authority sought to explore surgical complications and healthcare providers' responses by analyzing events reported as complications after surgery that resulted in permanent harm, near death, or death outcomes (high harm events). Analysts queried the Pennsylvania Patient Safety Reporting System for these high harm events submitted under the "complication following surgery or invasive procedure" event subtype for the 2017 academic year (i.e., 12 months ended June 2018). The query yielded 129 events of which cardiovascular and gastrointestinal procedures predominated (59.7%, n = 77 of 129). In these categories, bleeding and puncture, laceration, or tear were the most common complications (73.6%, n = 95 of 129). The majority of these high harm events (85.3%, n = 110 of 129) described some type of patient symptomatology to which healthcare providers responded 90.7% (n = 117 of 129) of the time. The majority of events resulted in death (65.1%, n = 84 of 129). Healthcare facilities can act now by using a similar analysis on their own cases and evaluate complication-response mechanisms to identify priorities for surgical-care learning and improvement.
Copyright:
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
Extent:
1 online resource (1 PDF file (17 pages))
Illustrations:
Illustrations
NLM Unique ID:
101739379 (See catalog record)