Evaluation and Outcome of Surgeon-Reported Incidents regarding Surgical Patient Safety

摘要

Background: We retrospectively analyzed incident reports from surgeons to learn about surgical patient safety and improve surgical quality. Material and Methods: For the 10 years and3 months between February 2007 and May 2017, 236 incident reports from surgeons were collected. The impact levels of the incidents for patients were represented by a degree of adverse influence to a patient (level 0, 1, 2, 3a, 3b, 4a, 4b, and 5). The outcome of the incident reports was evaluated by the profile, cause, surgery-relation, and factor. Results: The level of incidents resulted in level 0 (n = 18, 7.6%), level 1 (n = 28, 11.9%), level 2 (n = 16, 6.8%), level 3a (n = 44, 18.6%), level 3b (n = 94, 39.8%), level 4a (n = 1, 0.4%), level 4b (n = 6, 2.5%), level 5 (n = 15, 6.4%) and others (n = 14, 5.9%). The profiles of the surgery-related incidents (n = 84) showed other unexpected events (15.7%, n = 37), second surgery within 24 hours (9.3%, n = 22), and unexpected excessive bleeding (6.8%, n = 16). The cause of the sur-gery-related incidents involved hemorrhage (n = 45, 53.6%). Except for complications and accidental diseases (n = 77, 32.6%), the occurrence factor of the incidents cited factors of personal behavior (n = 85, 36.0%), human factors (n = 37, 15.7%), environmental equipment (n = 6, 2.5%), and others (n = 31, 13.1%). Conclusions: The perioperative incidents submitted by surgeons were comparatively proved to be a higher influence level for patients such as unexpected events or surgery and second surgery within 24 hours. An incident reporting system is crucial for surgeons to ensure both surgical patient safety and to improve surgical quality. An aggressive reporting attitude should become useful to enhance safety awareness on a facility-wide basis.