The challenge of learning from perioperative patient harm. (June 2016) - Wacker, Johannes
Abstract: Perioperative patient harm is frequent: Adverse events, more than half of them preventable, occur in about 30% of hospital admissions. Surgical in-hospital mortality in Europe is currently as high as 4% on average. Openly communicating as well as reporting patient harm are key to learning within institutions and improving patient outcomes, but are hindered by strong barriers in the tense working environment of perioperative healthcare. Some interventions to overcome such barriers and to improve patient outcomes are ready for adoption into routine practice. Before implementing safety interventions, specific institutional conditions should be considered to ensure local validity. Sustained improvements require local measurement and long-term monitoring of effects. Highlights: Perioperative adverse events are frequent and related to higher mortality. Openly communicating and reporting patient harm are key to institutional learning. Strong barriers may hamper perioperative communication and reporting. Interventions adopted to overcome such barriers should have local validity. Sustained outcome improvements may require long-term monitoring and intervention.