Background: The analysis of adverse events is a central step in critical incident reporting, but has not been described in a surgical setting. The aim of this study was to develop an evaluation protocol and assess its feasibility.
Methods: All incidents were analysed by a multidisciplinary team. A coding system based on three published theories was used to assess all incidents and their underlying causes. A risk analysis was also conducted.
Results: Between July 2004 and December 2005, 9785 inpatients were treated and 139 critical incidents reported. Classification of active errors revealed 47.7 per cent to be execution failures and 45.9 per cent knowledge-based errors. The distribution of medical errors was 12.9 per cent diagnostic, 46.0 per cent treatment, 17.3 per cent preventive and 23.7 per cent other. Some 282 latent failures were identified among the 139 incidents. Risk analysis revealed a severe incident rate of 21.6 per cent.
Conclusion: This study has shown the feasibility of an evaluation protocol based on a combination of three classification systems and a risk analysis. It allows a thorough assessment of critical incidents, identification of priorities and tailored countermeasures.
Copyright (c) 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.