Building a framework for trust: critical event analysis of deaths in surgical care

Abstract

The British public's confidence in doctors and hospitals has been dented in recent years. Use of an independent review of deaths before, during, or after surgery reflects an attempt to improve care in this area and may also help to restore the public's trust in their health service

Fig 1

The pathway of data gathering and assessment starts with a surgical death and proceeds through the critical event pathway. Where there is a cause for consideration or concern, an adverse event may be identified and a case-note review requested. For 10% of the deaths where no adverse event is identified, the case is reassessed. The assessments and review are fed back to the individual clinician, who has the right to reply or request a further review, leading to a final feedback to the clinicians involved in the care of the patient before death

Fig 2

Percentage of operations at which consultants have an input in various ways, 1994 to 2003

Fig 3

Percentage of deaths in surgical care for which adverse events in management were identified as contributing to death, 1994 to 2003

Fig 4

Percentage of deaths in surgical care for which adverse events in management were identified as causing death, 1994 to 2003

Fig 5

Percentage of deaths for which “failure to use a high dependency unit/intensive care unit” was cited as an adverse event, 1994 to 2003