Adverse events in surgical patients: incidence, characteristics and associated factors

Authors

DOI:

https://doi.org/10.5327/Z1414-4425202328890890

Keywords:

Patient safety, Medical errors, Surgical procedures, operative, Perioperative nursing

Abstract

Objective: To estimate the incidence of adverse events and identify the factors associated with their occurrence in surgical patients at a general reference hospital in the interior of Minas Gerais, Brazil. Method: Retrospective and documentary study carried out in 851 medical records of patients undergoing surgical procedures. To track and identify the adverse event, an adaptation of the Global Trigger Tool method was used, with double review of documents independently and data analysis using descriptive statistics, x2 test, Student’s t-test and logistic regression. Results: 145 adverse events were identified in 108 medical records, more than half related to complications at the surgical site, such as bleeding and surgical site infections. Prolonged hospital stay, duration of surgery longer than four hours and surgical procedures classified as contaminated were associated with greater chances of adverse event occurrence (p<0.001). Conclusion: Adverse events in surgical care have a high frequency and impact of damage caused, reinforcing the importance of strategies aimed at the safety of surgical patients.

Author Biographies

Luciane Ribeiro de Faria, Universidade Federal de Juiz de Fora – Juiz de Fora (MG), Brasil.

Enfermeira, Doutora em Saúde Coletiva, Departamento de Enfermagem Aplicada, Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brasil.

Andre Luiz Silva Alvim, Universidade Federal de Juiz de Fora – Juiz de Fora (MG), Brasil.

Enfermeiro. Professor Adjunto da Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brasil.

Hérica Silva Dutra, Universidade Federal de Juiz de Fora – Juiz de Fora (MG), Brasil.

Enfermeira, Doutora em Enfermagem, Departamento de Enfermagem Básica, Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brasil.

Fábio da Costa Carbogim, Universidade Federal de Juiz de Fora – Juiz de Fora (MG), Brasil.

Enfermeiro, Doutora em Enfermagem, Departamento de Enfermagem Básica, Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brasil.

Claudilene Fernandes da Silva, Universidade Federal de Juiz de Fora – Juiz de Fora (MG), Brasil.

Enfermeira, Mestranda em Enfermagem, HU/EBSERH, Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brasil.

Ronaldo Rocha Bastos, Universidade Federal de Juiz de Fora – Juiz de Fora (MG), Brasil.

. Engenheiro civil, Doutor em Planejamento Regional e Urbano, Departamento de Estatística, Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brasil.

References

Decormeille G, Maurer-Maouchi V, Mercier G, Debock S, Lebrun C, Rouhier M, et al. Adverse events in intensive care and continuing care units during bed-bath procedures: the prospective observational NURSIng during critical carE (NURSIE) study. Crit Care Med. 2021;49(1):e20-e30. https://doi.org/10.1097/CCM.0000000000004745 DOI: https://doi.org/10.1097/CCM.0000000000004745

Wain H, Kong V, Bruce J, Laing G, Clarke D. Analysis of surgical adverse events at a major University Hospital in South Africa. World J Surg. 2019;43(9):2117-22. https://doi.org/10.1007/s00268-019-05008-9 DOI: https://doi.org/10.1007/s00268-019-05008-9

Tanaka K, Erikssom L, Asher R, Obermair A. Incidence of adverse events, preventability and mortality in gynaecological hospital admissions: a systematic review and meta-analysis. Aust N Z J Obster Gynaecol. 2019;59(2):195-200. https://doi.org/10.1111/ajo.12937 DOI: https://doi.org/10.1111/ajo.12937

Cheng A, Kessler D, Mackinnon R, Chang TP, Nadkarni VM, Hunt EA, et al. Reporting guidelines for health care simulation research: extensions to the CONSORT and STROBE statements. Simul Healthc. 2016;11(4):238-48. https://doi.org/10.1097/SIH.0000000000000150 7. Machin D, Campbell M, Fayers P, Pinol A. A sample size tables for clinical studies. 2nd ed. Philadelphia: Blackwell Science; 1997.

Griffin F, Resar R. IHI Global trigger tool for measuring adverse events. 2nd ed. Cambridge: Institute for Healthcare Improvement; 2009.

Sousa LAO, Fonteles MMF, Monteiro MP, Mengue SS, Bertoldi AD, Dal Pizzol TS, et al. Prevalence and characteristics of adverse drug events in Brazil. Cad Saúde Pública. 2018;34(4):e00040017. https://doi.org/10.1590/0102-311X00040017 DOI: https://doi.org/10.1590/0102-311x00040017

Turrentine FE, Schenk WG, McMurry TL, Tache-Leon CA, Jones RS. Surgical errors and the relationships of disease, risks, and adverse events. Am J Surg. 2020;220(6):1572-8. https://doi.org/10.1016/j.amjsurg.2020.05.004 DOI: https://doi.org/10.1016/j.amjsurg.2020.05.004

Srinivasa S, Gurney J, Koea J. Potential consequences of patient complications for surgeon well-being: a systematic review. JAMA Surg. 2019;154(5):451-7. https://doi.org/10.1001/jamasurg.2018.5640 DOI: https://doi.org/10.1001/jamasurg.2018.5640

Sataloff RT. Adverse surgical events: effects on the surgeon. Ear Nose Throat J. 2020;99(4):225-6. https://doi.org/10.1177/0145561319827704 DOI: https://doi.org/10.1177/0145561319827704

Roque KE, Tonini T, Melo ECP. Eventos adversos na unidade de terapia intensiva: impacto na mortalidade e no tempo de internação em um estudo prospectivo. Cad Saúde Pública. 2016;32(10):e00081815. https://doi.org/10.1590/0102-311X00081815 DOI: https://doi.org/10.1590/0102-311X00081815

Hibbert PD, Molloy CJ, Hooper TD, Wiles LK, Runciman WB, Lachman P et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care. 2016;28(6):640-9. https://doi.org/10.1093/intqhc/mzw115 DOI: https://doi.org/10.1093/intqhc/mzw115

Ruiz OG, Lázaro JPP, López RP. Rendimiento y optimización de la herramienta trigger en la detección de eventos adversos en pacientes adultos hospitalizados. Gac Sanit. 2017;31(6):453-8. https://doi.org/10.1016/j.gaceta.2017.01.014 DOI: https://doi.org/10.1016/j.gaceta.2017.01.014

Pineda-Pérez D, Puentes-Rosas E, Rangel-Chávez NJ, Garrido-Latorre F. Eventos quirúrgicos adversos em três instituciones públicas de salud mexicanas. Salud Pública Méx. 2011;53(Suppl 4):484-90.

Nonaka M, Morishita T, Yamada K, Fujioka S, Higuchi MA, Tsuboi Y, et al. Surgical management of adverse events associated with deep brain stimulation: a single-center experience. SAGE Open Med. 2020;8:2050312120913458. https://doi.org/10.1177/2050312120913458 DOI: https://doi.org/10.1177/2050312120913458

Suliburk JW, Buck QM, Pirko CJ, Massarweh NN, Barshes NR, Singh H, et al. Analysis of human performance deficiencies associated with surgical adverse events. JAMA Netw Open. 2019;2(7):e198067. https://doi.org/10.1001/jamanetworkopen.2019.8067 DOI: https://doi.org/10.1001/jamanetworkopen.2019.8067

Maia CS, Freitas DRC, Gallo LG, Araújo WN. Notificações de eventos adversos relacionados com a assistência à saúde que levaram a óbitos no Brasil, 2014-2016. Epidemiol Serv Saude. 2018;27(2):e2017320. https://doi.org/10.5123/S1679-49742018000200004 DOI: https://doi.org/10.5123/S1679-49742018000200004

van der Vlis TAMB, van de Veerdonk MMGH, Ackermans L, Leentjens AFG, Janssen MLF, Kuijf ML, et al. Surgical and hardware-related adverse events of deep brain stimulation: a ten-year single-center experience. Neuromodulation. 2022;25(2):296-304. https://doi.org/10.1016/j.neurom.2021.12.011 DOI: https://doi.org/10.1016/j.neurom.2021.12.011

Published

2023-09-28

How to Cite

de Faria, L. R., Alvim, A. L. S., Dutra, H. S., Carbogim, F. da C., da Silva, C. F., & Bastos, R. R. (2023). Adverse events in surgical patients: incidence, characteristics and associated factors. Revista SOBECC, 28. https://doi.org/10.5327/Z1414-4425202328890890

Issue

Section

ORIGINAL ARTICLES