Cardiac surgery errors: results from the UK National Reporting and Learning System

Objective. To describe cardiac surgery-related incidents and compare the types and severity of incidents occurring in the operating room (OR) versus non-OR locations. We hypothesized that the type and severity of incidents in cardiac surgery would differ in the OR compared with non-OR locations. Des...

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Bibliographic Details
Published in:International journal for quality in health care 2011-04, Vol.23 (2), p.151-158
Main Authors: MARTINEZ, ELIZABETH A., SHORE, ANDREW, COLANTUONI, ELIZABETH, HERZER, KURT, THOMPSON, DAVID A., GURSES, AYSE P., MARSTELLER, JILL A., BAUER, LAURA, GOESCHEL, CHRISTINE A., CLEARY, KEVIN, PRONOVOST, PETER J., PHAM, JULIUS CUONG
Format: Article
Language:English
Subjects:
Cardiac Surgical Procedures - standards
Cross-Sectional Studies
Female
Humans
Intraoperative Complications - classification
Intraoperative Complications - epidemiology
Male
Medical Errors - classification
Medical Errors - statistics & numerical data
Middle Aged
Operating Rooms - statistics & numerical data
Postoperative Complications - classification
Postoperative Complications - epidemiology
Retrospective Studies
Risk Management - classification
Risk Management - statistics & numerical data
State Medicine - statistics & numerical data
Trauma Severity Indices
United Kingdom - epidemiology
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Summary:Objective. To describe cardiac surgery-related incidents and compare the types and severity of incidents occurring in the operating room (OR) versus non-OR locations. We hypothesized that the type and severity of incidents in cardiac surgery would differ in the OR compared with non-OR locations. Design. A retrospective cross-sectional study of all incidents categorized as cardiac surgery in the UK National Reporting and Learning System database between January 2003 and February 2007. Differences in proportions were evaluated by χ² or Fischer's exact test. The odds ratio of an event occurring in the OR compared with all non-OR settings was calculated using logistic regression. The harm susceptibility ratio ranked locations by the degree of harm. Setting. All trusts performing cardiac surgery. Participants. None. Intervention. None. Main Outcome Measures. Cardiac surgery incidents occurring in the OR versus non-OR. Results. A total of 4828 (
ISSN:1353-4505
1464-3677
DOI:10.1093/intqhc/mzq084