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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Article info
Publication history
Published online: May 12, 2008
Received:
January 5,
2008
Identification
Copyright
© 2009 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
