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A Report Card System Using Error Profile Analysis and Concurrent Morbidity and Mortality Review: Surgical Outcome Analysis, Part II

      Background

      An effective report card system for adverse outcome error analysis following surgery is lacking. We hypothesized that a memorialized database could be used in conjunction with error analysis and management evaluation at Morbidity & Mortality conference to generate individualized report cards for Attending Surgeon and System performance.

      Study Design

      Prospectively collected data from September 2000 through April 2005 were reported following Morbidity & Mortality review on 1618 adverse outcomes, including 219 deaths, following 29,237 operative procedures, in a complete loop to approximately 60 individual surgeons and responsible system personnel.

      Results

      A 40% reduction of gross mortality (P < 0.001) and 43% reduction of age-adjusted mortality were achieved over 4 years at the Academic Center. Quality issues were identified at a rate three times greater than required by New York State regulations and increased from a baseline 4.96% to 32.7% (odds ratio 1.94; P < 0.03) in cases associated with mortality. A detailed review demonstrated a significant increase (P < 0.001) in system errors and physician-related diagnostic and judgment errors associated with mortality highlighted those practices and processes involved, and contrasted the results between academic (43% mortality improvement) and community (no improvement) hospitals.

      Conclusions

      The findings suggest that structured concurrent data collection combined with non-punitive error-based case review and individualized report cards can be used to provide detailed feedback on surgical performance to individual surgeons and possibly improve clinical outcomes.

      Key Words

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      References

        • Shahian D.M.
        • Normand S.L.
        • Torchiana D.F.
        • et al.
        Cardiac surgery report cards: Comprehensive review and statistical critique.
        Ann Thorac Surg. 2001; 72: 2155
        • Murayama K.M.
        • Derossis A.M.
        • DaRossa D.A.
        • et al.
        A critical evaluation of the morbidity and mortality conference.
        Am J Surg. 2002; 183: 246
        • Russell E.M.
        • Bruce J.
        • Krukowski Z.H.
        Systematic review of the quality of surgical mortality monitoring.
        Br J Surg. 2003; 90: 527
        • Martin L.F.
        • O'Leary J.P.
        The surgeon's role in improving medical care.
        Am J Surg. 1997; 174: 294
        • Hutter M.M.
        • Rowell D.S.
        • Devaney L.A.
        • et al.
        Identification of surgical complications and deaths: An assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program.
        J Am Coll Surg. 2006; 203: 618
      1. Cancer Therapy Evaluation Program, Common Terminology Criteria for Adverse Events, Version 3.0, DCTD, NCI, HIH, DHHS. March 31, 2002 (http://ctep.cancer.gov), Publish Date: June 10, 2003.

        • Rooney J.J.
        • Vanden Heuvel L.N.
        Root cause analysis for beginners.
        Qual Prog. 2004; 45
        • Brown S.L.
        • Woo E.K.
        Surgical stapler-associated fatalities and adverse events reported to the Food and Drug Administration.
        J Am Coll Surg. 2004; 199: 374
        • Reason J.
        Education and debate: Human error: models and management.
        Br Med J. 2000; 320: 768
        • Clarke J.R.
        Making surgery safer.
        J Am Coll Surg. 2005; 2: 229