In 2016, Surgery and Invasive Procedure events were among the top 10 reported event types reported in Quantros Safety Event Manager. These events could include incidental complications, iatrogenic complications, pre-operative issues, intra-operative issues, or best practices issues. Some examples of these complications and issues include blood loss or hemorrhage, cardiac arrest, air embolism, retained surgical item, wrong site, wrong side, patient safety checklist not used, non-sterile equipment used, and more.
The Centers for Medicare & Medicaid Services (CMS) defines surgical and other invasive procedures as “operative procedures in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice” (Centers for Medicare & Medicaid Services, 2009). These procedures can range from biopsies and laparoscopic procedures to multi-organ transplantation or limb removals.
Of the surgery and invasive procedure events reported in 2016, 19% resulted in temporary or permanent harm (Categories E-H).
Severity Breakdown of Adverse Events During Surgery & Invasive Procedures in 2016
Source: National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Medication Errors
COSTS ASSOCIATED WITH SURGICAL COMPLICATIONS
Recent studies of the financial burden absorbed by hospitals for cases involving surgical adverse events is best reflected in their overall profit margins, which on average decrease from 5.8% for patients without compensation to 0.1% for patients with complications (Healy, Mullard, Campbell Jr., & Dimick, 2016). Malpractice claims also pose a financial burden to hospitals and surgeons. An analysis of medical malpractice payouts in 2016 found that 24% of payment amounts by malpractice allegation were related to surgery (Diederich Healthcare, 2017). The total amount of medical malpractice payouts including all specialties in 2016 was $3,843,211,300. Surgical never events, which are those serious and often preventable medical errors that should never occur, include wrong-site surgery, unintended retention of a foreign object in a patient after surgery, surgery performed on the wrong patient, and more. A study of malpractice claims associated with surgical never events occurring between 1990 and 2010 found malpractice payments totaling $1.3 billion during the 20 year time period (Mehtsun, Ibrahim, Diener-West, Pronovost, & Makary, 2013). This study estimates that 4,082 surgical never event claims occur annually in the U.S.
Adverse events associated with surgery and invasive procedures are painful and cause damage to the patient who experiences the complication. These events are also a financial burden to hospitals and surgeons and impact the hospital’s overall profit margin. Prevention plans may include increased transparency into events through reporting policies and increased communication and mandatory checks by multiple people on the surgical team preceding the procedure.
HELPFUL TOOLS AND REFERENCES
- Centers for Medicare & Medicaid Services. (2009, June 12). CMS Manual System Pub 100-03 Medicare National Coverage Determinations. Retrieved from CMS.gov
- Clarke, J. R., Johnston, J. M., & Finley, E. D. (2007). Getting Surgery Right. Annals of Surgery, 395-405.
- Diederich Healthcare. (2017, February 27). 2017 Medical Malpractice Payout Analysis. Retrieved from Diederich Healthcare
- Health Research & Educational Trust and Joint Commission Center for Transforming Healthcare. (2014). Reducing the risks of wrong-site surgery: Safety practices from The Joint Commission Center for Tranforming Healtcare project. Chicago: Health
- Research & Educational Trust.
- Healy, M. A., Mullard, A. J., Campbell Jr., D. A., & Dimick, J. B. (2016). Hospital and Payer Costs Associated with Surgical Complications. JAMA Surgery, 823-830.
- Kwaan, M., Studdert, D., Zinner, M., & Gawande, A. (2006). Incidence, Patterns, and Prevention of Wrong-Site Surgery. Archives of Sugery, 353-358.
- Mehtsun, W. T., Ibrahim, A. M., Diener-West, M. P., Pronovost, P. J., & Makary, M. A. (2013). Surgical never events in the United States. Surgery, 465-472.
- Shreve, J., Van Den Bos, J., Gray, T., Halford, M., Rustagi, K., & Ziemkiewicz, E. (2010). The Economic Measurement of Medical Errors. Milliman.
Quantros’ mission and vision is to deliver solutions that dynamically monitor risks, measure financial and clinical performance and enable the quality improvements that make care safer. As a trusted value-based partner, our Software-as a-Service (SaaS) applications help thousands of hospitals, retail pharmacies and some of the nation’s largest health systems to capture actionable intelligence, reduce risks and reinforce their commitment to delivering cost-effective, safety-centered, high quality medical care.
The Quantros® Safety and Risk Management Solutions Suite enables healthcare providers to improve quality and patient safety by providing the information they need to prevent errors, improve outcomes, reduce risks and costs. Quantros offers a single access point for users to manage their safety-related claims, risk, event, and reporting activities. The applications support the reduction of patient safety events via automated alerts, real-time reporting and sophisticated root-cause analysis. Organizations can use the application to correct an error prone environment, reducing cost and the loss of internal resources.