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.
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