A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II

J Surg Res. 2009 May 1;153(1):95-104. doi: 10.1016/j.jss.2008.02.051. Epub 2008 Mar 31.


Background: An effective report card system for adverse outcome error analysis following surgery is lacking. We hypothesized that a memorialized database could be used in conjunction with error analysis and management evaluation at Morbidity & Mortality conference to generate individualized report cards for Attending Surgeon and System performance.

Study design: Prospectively collected data from September 2000 through April 2005 were reported following Morbidity & Mortality review on 1618 adverse outcomes, including 219 deaths, following 29,237 operative procedures, in a complete loop to approximately 60 individual surgeons and responsible system personnel.

Results: A 40% reduction of gross mortality (P < 0.001) and 43% reduction of age-adjusted mortality were achieved over 4 years at the Academic Center. Quality issues were identified at a rate three times greater than required by New York State regulations and increased from a baseline 4.96% to 32.7% (odds ratio 1.94; P < 0.03) in cases associated with mortality. A detailed review demonstrated a significant increase (P < 0.001) in system errors and physician-related diagnostic and judgment errors associated with mortality highlighted those practices and processes involved, and contrasted the results between academic (43% mortality improvement) and community (no improvement) hospitals.

Conclusions: The findings suggest that structured concurrent data collection combined with non-punitive error-based case review and individualized report cards can be used to provide detailed feedback on surgical performance to individual surgeons and possibly improve clinical outcomes.

MeSH terms

  • Academic Medical Centers / standards
  • Academic Medical Centers / statistics & numerical data
  • Databases, Factual
  • Humans
  • Medical Errors / mortality
  • Medical Errors / statistics & numerical data*
  • Morbidity
  • New York City
  • Outcome Assessment, Health Care / methods*
  • Peer Review / methods
  • Prospective Studies
  • Quality Assurance, Health Care / methods*
  • Safety Management*