VIEWS: 3 PAGES: 3 CATEGORY: Medicine POSTED ON: 6/13/2010
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Online Reporting System Could Track Surgical Complications Web-based reporting system may help clinicians track surgical In addition, the morbidity and mortality conference typically does A complications and detect patterns of adverse events, identify- ing opportunities to improve the quality of care, according to a report in the April issue of Archives of Surgery, one of the JAMA/ not address near-misses, events that had the potential to result in an adverse outcome and can offer valuable learning opportunities. Karl Bilimoria, MD, MS, of Feinberg School of Medicine, Northwestern Archives journals. University, Chicago and colleagues designed a Web-based system to Complications and deaths during surgery are typically discussed track adverse and near-miss events and also established an automated by clinicians at a weekly surgical morbidity and mortality conference, method to identify patterns of these events. The system was imple- according to background information in the article. “Individual cases mented at a large metropolitan tertiary care center in September are typically presented by a resident, and a discussion ensues address- 2005. Residents entered data about adverse events used for the ing the issues in that single case,” the authors wrote. “Recent efforts morbidity and mortality conference, and all clinicians in the surgery have attempted to make the discussion more evidence-based and less department were given a password to anonymously enter information blame-oriented. However, the focus has remained on individual cases, residents, and physicians rather than on the system and overall qual- ity of patient care.” Continues on page 12 « www.aana.com S June 2009 S AANA NewsBulletin 11 «Continued from page 11 about other adverse events and near misses. initiated. “Though not surprising, this under-reporting was disap- Through August 2007, 15,524 surgical patients were reported pointing,” the authors wrote. “During the study period, interventions including 957 (6.2 percent) adverse events and 34 (0.2 percent) aimed at increasing reporting had little effect.” A presentation from anonymous reports. “The automated pattern recognition system the department chair regarding what constitutes an adverse event an
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