Understanding ultrarare adverse events - Lessons learned from a twelve-year review of intraoperative deaths at an academic medical center

Abstract

Background: Intraoperative death (ID) is rare, the incidence remains challenging to quantify and learning opportunities are limited. We aimed to better define the demographics of ID by reviewing the longest single-site series.

Methods: Retrospective chart reviews, including a review of contemporaneous incident reports, were performed on all ID between March 2010 to August 2022 at an academic medical center.

Results: Over 12 years, 154 IDs occurred (∼13/year, average age: 54.3 years, male: 60%). Most occurred during emergency procedures (n = 115, 74.7%), 39 (25.3%) during elective procedures. Incident reports were submitted in 129 cases (84%). 21 (16.3%) reports cited 28 contributing factors including challenges with coordination (n = 8, 28.6%), skill-based errors (n = 7, 25.0%), and environmental factors (n = 3, 10.7%).

Conclusions: Most deaths occurred in patients admitted from the ER with general surgical problems. Despite expectations for incident reporting, few provided actionable information on ergonomic factors which might help identify improvement opportunities.

Keywords: Adverse events; Ergonomics; Human factors; Intraoperative death; Patient safety; Retrospective review.