Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients

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Abstract

Objectives: To design a Web-based system to track adverse and near-miss events, to establish an automated method to identify patterns of events, and to assess the adverse event reporting behavior of physicians. Design:A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness. Setting: A metropolitan tertiary care center. Main Outcome Measures: Identification of adverse event patterns and completeness of reporting. Results: From September 2005 to August 2007, 15 524 surgical patients were reported including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25% of complications and 42% of inpatient deaths were reported. A total of 75.2% of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful. Conclusions: We have developed a user-friendly Webbased system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities. Arch Surg. 2009;144(4):305-311

Original languageEnglish (US)
Pages (from-to)305-311
Number of pages7
JournalArchives of Surgery
Volume144
Issue number4
DOIs
StatePublished - Apr 1 2009

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Automated Pattern Recognition
Morbidity
Physicians
Mortality
Quality Improvement
Tertiary Care Centers
Teaching Hospitals
Inpatients
Outcome Assessment (Health Care)
Databases

ASJC Scopus subject areas

  • Surgery

Cite this

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title = "Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients",
abstract = "Objectives: To design a Web-based system to track adverse and near-miss events, to establish an automated method to identify patterns of events, and to assess the adverse event reporting behavior of physicians. Design:A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness. Setting: A metropolitan tertiary care center. Main Outcome Measures: Identification of adverse event patterns and completeness of reporting. Results: From September 2005 to August 2007, 15 524 surgical patients were reported including 957 (6.2{\%}) adverse events and 34 (0.2{\%}) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25{\%} of complications and 42{\%} of inpatient deaths were reported. A total of 75.2{\%} of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful. Conclusions: We have developed a user-friendly Webbased system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities. Arch Surg. 2009;144(4):305-311",
author = "Bilimoria, {Karl Y} and Kmiecik, {Thomas E.} and Debra DaRosa and Halverson, {Amy L} and Mark Eskandari and Bell, {Richard H.} and Soper, {Nathaniel J} and Wayne, {Jeffrey D}",
year = "2009",
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T1 - Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients

AU - Bilimoria, Karl Y

AU - Kmiecik, Thomas E.

AU - DaRosa, Debra

AU - Halverson, Amy L

AU - Eskandari, Mark

AU - Bell, Richard H.

AU - Soper, Nathaniel J

AU - Wayne, Jeffrey D

PY - 2009/4/1

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N2 - Objectives: To design a Web-based system to track adverse and near-miss events, to establish an automated method to identify patterns of events, and to assess the adverse event reporting behavior of physicians. Design:A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness. Setting: A metropolitan tertiary care center. Main Outcome Measures: Identification of adverse event patterns and completeness of reporting. Results: From September 2005 to August 2007, 15 524 surgical patients were reported including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25% of complications and 42% of inpatient deaths were reported. A total of 75.2% of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful. Conclusions: We have developed a user-friendly Webbased system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities. Arch Surg. 2009;144(4):305-311

AB - Objectives: To design a Web-based system to track adverse and near-miss events, to establish an automated method to identify patterns of events, and to assess the adverse event reporting behavior of physicians. Design:A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness. Setting: A metropolitan tertiary care center. Main Outcome Measures: Identification of adverse event patterns and completeness of reporting. Results: From September 2005 to August 2007, 15 524 surgical patients were reported including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25% of complications and 42% of inpatient deaths were reported. A total of 75.2% of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful. Conclusions: We have developed a user-friendly Webbased system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities. Arch Surg. 2009;144(4):305-311

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