An Online Reporting System Could Track Surgical Complications

The system was implemented at a large metropolitan tertiary care center in September 2005. Residents entered data about adverse events used for the hospital morbidity and mortality conference, and all clinicians in the surgery department were given a password to anonymously enter additional information about other adverse events and near misses.

The researchers found that through August 2007, 15,524 surgical patients were reported, including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The events entered into the online system were also compared with hospital databases to assess the completeness of reporting. Only 27.2% (264 of 970) of readmissions and 41.6% (89 of 214) of inpatient deaths were reported into the system; there was no change in monthly adverse reporting rate when the online system was initiated. The researchers were disappointed with the under-reporting of events, and a subsequent presentation from the department chair regarding what constitutes an adverse event and the importance of tracking complications produced an initial spike in reporting that was unfortunately short-lived. However, the automated pattern recognition system helped identify four event patterns from morbidity and mortality reports and three patterns from anonymous and near miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and intensive quality monitoring. For example, recurring errors in chest tube placements and nurse-to-physician communications were detected and managed. The study describing the implementation of the system was reported in the April 2009 issue of the journal Archives of Surgery.

"An electronic physician-reported event tracking system should be incorporated into all surgery departments irrespective of whether the department is associated with a residency program; however, this is just one component of what should be a larger quality improvement effort," concluded lead author Karl Bilimoria, M.D., M.Sc., and colleagues. "An online event tracking system is a feasible, promising and potentially powerful initiative to improve surgical safety in the United States."

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