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Anthony C. Antonacci, MD, SM; Steven Lam, PA; Valentina Lavarias, RN, MA; Peter Homel, PhD; Roland D. Eavey, MD, SM

Arch Surg. 2008;143(12):1192-1197.

Objective  To study the profile of incidents affecting quality outcomes after surgery by developing a usable operating room and perioperative clinical incident report database and a functional electronic classification, triage, and reporting system. Previously, incident reports after surgery were handled on an individual, episodic basis, which limited the ability to perceive actuarial patterns and meaningfully improve outcomes.

Design, Setting, and Participants  Clinical incident reports were experientially generated in the second largest health care system in New York City. Data were entered into a functional classification system organized into 16 categories, and weekly triage meetings were held to electronically review and report summaries on 40 to 60 incident reports per week. System development and deployment reviewed 1041 reports after 19 693 operative procedures. During the next 4 years, 3819 additional reports were generated from 83 988 operative procedures and were reported electronically to the appropriate departments.

Main Outcome Measures  Number of incident reports generated annually.

Results  A significant decrease in volume-adjusted clinical incident reports occurred (from 53 to 39 reports per 1000 procedures) from 2001 to 2005 (P < .001). Reductions in incident reports were observed for ambulatory conversions (74% reduction), wasted implants (65%), skin breakdown (64%), complications in the operating room (42%), laparoscopic conversions (32%), and cancellations (23%) as a result of data-focused process and clinical interventions. Six of 16 categories of incident reports accounted for more than 88% of all incident reports.

Conclusion  These data suggest that effective review, communication, and summary feedback of clinical incident reports can produce a statistically significant decrease in adverse outcomes.

Author Affiliations: Department of Surgery, Weill Medical College of Cornell University, New York, New York (Dr Antonacci); Department of Medical Affairs and Quality Improvement, Christ Hospital, Jersey City, New Jersey (Dr Antonacci); Department of Surgery, Lenox Hill Hospital, New York (Mr Lam); Departments of Surgery (Dr Antonacci and Ms Lavarias) and Pain Management and Palliative Care (Dr Homel), Beth Israel Medical Center, New York; Pediatric Otolaryngology Service, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, and Department of Otology and Laryngology, Harvard Medical School, Boston (Dr Eavey).

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