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Original article
An easy, prompt and reproducible methodology to manage an unexpected increase of incident reports in surgery theatres
  1. Adriana Moccia1,
  2. Rosanna Quattrin1,
  3. Claudio Battistella2,
  4. Elisa Fabbro2,
  5. Silvio Brusaferro2
  1. 1 Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
  2. 2 Department of Medicine, Università degli Studi di Udine, Udine, Italy
  1. Correspondence to Dr Adriana Moccia; adriana.moccia{at}asuiud.sanita.fvg.it

Abstract

Objectives Surgery is a high-risk hospital area for adverse events (AEs) occurrence. This study aims to develop an effectiveness and reactive methodology to manage an unexpected increase of AEs in the operating rooms (ORs) of a large Academic Hospital providing about 30 000 surgeries per year.

Methods The study included three phases: 1. analysis of the AEs collected through the hospital incident reporting system from 2014 to 2015; 2. development of a programme to improve the surgical patient’s safety and 3. application and evaluation of the programme effectiveness.

Results In 2014, all hospital AEs were 825 (10.3% in ORs), while in the first 5 months of 2015, they were 645 (17.7% in ORs) [relative risk (RR) 2015 vs 2014=1.7; 95% CI=1.3 to 2.2; p<0.0001] with two sentinel events. Due to this increase, 177 real-time observations were planned in 12 ORs with external staff (n.25) during 1 week in June, July and November 2015 using a checklist with 14 items related to the patient’s pathway (surgical site, time-out, medical records and sponges count). After the observations, the AEs decreased from 11.4×1000 surgeries (January–June 2015) to 8.6×1000 (July–December 2015) (RR=0.7, 95% CI=0.6 to 0.9, p<0.05). Compliance to the correct procedures applied by ORs staff has improved during the year for all items.

Conclusions The methodology of this study has been revealed effective to control an unexpected increase in AEs and to improve the healthcare workers’ adherence to correct procedures and it could be translated in other patients’ safety settings.

  • adverse events
  • operating rooms
  • real-time observations

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjoq-2017-000147

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    Footnotes

    • Contributors AM: conceptualised and designed the study and the data collection instruments, collected data, carried out the analyses and drafted the initial manuscript. RQ: conceptualised and designed the study, supervised data collection, carried out the analyses, reviewed and revised the manuscript. CB: conceptualised and designed the study and the data collection instruments, collected data and carried out the analyses. EF: reviewed and revised the manuscript. SB: critically reviewed the manuscript and approved the final manuscript as submitted.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.