Cardiac surgery errors: results from the UK National Reporting and Learning System

Abstract

Objective: To describe cardiac surgery-related incidents and compare the types and severity of incidents occurring in the operating room (OR) versus non-OR locations. We hypothesized that the type and severity of incidents in cardiac surgery would differ in the OR compared with non-OR locations.

Design: A retrospective cross-sectional study of all incidents categorized as cardiac surgery in the UK National Reporting and Learning System database between January 2003 and February 2007. Differences in proportions were evaluated by χ(2) or Fischer's exact test. The odds ratio of an event occurring in the OR compared with all non-OR settings was calculated using logistic regression. The harm susceptibility ratio ranked locations by the degree of harm.

Setting: All trusts performing cardiac surgery.

Participants: None.

Intervention: None.

Main outcome measures: Cardiac surgery incidents occurring in the OR versus non-OR.

Results: A total of 4828 (<1%) incidents from 55 trusts were designated as involving cardiac surgery patients during the study period; 21% occurred in the OR. Overall, 32% of incidents resulted in harm: 23% of OR and 34% of non-OR incidents. The distribution of incident type and harmful incidents differed in the OR compared with the non-OR setting (P < 0.05).

Conclusions: Our findings offer unique insights into the types of incidents occurring during cardiac surgical care in the UK. In the OR, interventions should focus on reducing errors associated with medical devices/equipment, whereas outside the OR, they may focus on medication errors and patient accidents.