JCAHO data show surgical complications, causes

Post-op procedures are particularly risky

The latest data analysis from the Joint Commission on Accreditation of Healthcare Organizations shows there have been 64 sentinel events related to operative and postoperative complications since the events were first tracked four years ago.

The report from the Joint Commission shows that 84% of the complications resulted in patient deaths, while 16% resulted in serious injury. All of the cases occurred in acute care hospitals. Cases directly related to medication errors or to the administration of anesthesia were not included in the analysis.

Fifty-eight percent of the complications occurred during the post-operative procedure period, 23% during intraoperative procedures, 13% during post-anesthesia recovery, and 6% during anesthesia induction.

Nonemergent cases dominate list

The types of pro cedures most frequently associated with the reported complications included interventional imaging and/or endoscopy, tube or catheter insertion, open abdominal surgery, head and neck surgery, orthopedic surgery, and thoracic surgery. Ninety percent of the 64 cases reviewed occurred in relation to nonemergent procedures.

These were the most frequent complications by type of procedure:

• nasogastric/feeding tube insertion into the trachea or a bronchus;

• massive fluid overload from absorption of irrigation fluids during genitourinary/gynecological procedures;

• open orthopedic procedures associated with acute respiratory failure, including cardiac arrest in the operating room;

• endoscopic procedures (including nongastrointestinal procedures) with perforation of adjacent organs. Liver lacerations were among the most frequent complications of abdominal and thoracic endoscopic surgery;

• central venous catheter insertion into an artery;

• imaging-directed percutaneous biopsy or tube placement resulting in liver laceration, peritonitis, or respiratory arrest while temporarily off prescribed oxygen;

• burns from electrocautery used with a flammable prep solution;

• complications associated with misplacement of tubes or catheters usually involved a failure to confirm the position of the tube or catheter (usually radiographically), misinterpretation of the radiographic image by a nonradiologist, or a failure to communicate the results of the confirmation procedure.

Root causes fall into eight categories

The hospitals identified eight root causes in the 64 cases. Two-thirds of the hospitals identified incomplete communication among caregivers as a root cause, while more than half mentioned failure to follow established procedures. These were the other six root causes:

• necessary personnel not being available when needed;

• preoperative assessment being incomplete;

• deficiencies in credentialing and privileging;

• inadequate supervision of house staff;

• inconsistent postoperative monitoring procedures;

• failure to question inappropriate orders;

The organizations that experienced complications also identified risk reduction strategies, with 80% recommending improved staff orientation and training. These were some other suggested strategies:

• educating and counseling physicians;

• expanding on-call coverage, especially in radiology;

• standardizing procedures across settings of care;

• revising credentialing and privileging procedures;

• clearly defining expected channels of communication;

• revising the competency evaluation process;

• monitoring consistency of compliance with procedures;

• implementing a teleradiology program.