Operative and Post-Operative Complications: Lessons for the Future

Since the Joint Commission began tracking sentinel events nearly four

Experts say that organizations should review post-operative patient monitoring procedures to ensure a comparable level of care as appropriate to the needs of the patient, regardless of the setting (operating room, endoscopy suite, radiology department, etc.) in which the procedure was done. "The monitoring of patients should be predicated on patient needs, not on locations. Proper communication between health care providers when dealing with patients is critical." Mark Malangoni, M.D American College of Surgeons

years ago, the Accreditation Committee of the Joint Commission's Board of Commissioners has reviewed 64 cases related to operative and post-operative complications. For each of the events reviewed, a root cause analysis was completed.

Eighty-four percent of the complications resulted in patient deaths, while 16 percent resulted in a serious injury. All of the cases occurred in acute care hospitals. Cases directly related to medication errors or to the administration of anesthesia are not included in this review.

Fifty-eight percent of the complications occurred during the post-operative procedure period, 23 percent during intraoperative procedures, 13 percent during post-anesthesia recovery, and 6 percent during anesthesia induction. The types of procedures most frequently associated with these reported complications included interventional imaging and/or endoscopy, tube or catheter insertion, open abdominal surgery, head and neck surgery, orthopedic surgery and thoracic surgery. Ninety percent of the 64 cases reviewed occurred in relation to non-emergent procedures.

The most frequent complications by type of procedure included the following:

• Naso-gastric/feeding tube insertion into the trachea or a bronchus.
• Massive fluid overload from absorption of irrigation fluids during genito-urinary/gynecological procedures.
• Open orthopedic procedures associated with acute respiratory failure, including cardiac arrest in the operating room.
• Endoscopic procedures (including non-gastrointestinal procedures) with perforation of adjacent organs. Liver lacerations were among the most frequent complications of abdominal and thoracic endoscopic surgery.
• Central venous catheter insertion into an artery.
• Imaging-directed percutaneous biopsy or tube placement resulting in liver laceration, peritonitis, or respiratory arrest while temporarily off prescribed oxygen.
• Burns from electrocautery used with a flammable prep solution.

Complications associated with misplacement of tubes or catheters usually involved a failure to confirm the position of the tube or catheter (usually radiographically), misinterpretation of the radiographic image by a non-radiologist, or a failure to communicate the results of the confirmation procedure.

Root Causes Identified by Hospitals Experiencing These Events

"Develop and use a system of checks and balances and recognize and respect every member of the team. People know how to do the right thing, but they need to be more conscientious, listen to their team members and work together as a group." Dorothy Fogg, R.N., B.S.N., M.A. Association of PeriOperative Registered Nurses

Hospitals identified eight root causes in the 64 cases. Two-thirds of the hospitals identified incomplete communication among caregivers as a root cause, while more than half mentioned failure to follow established procedures. The six other root causes included the following:

• Necessary personnel not being available when needed.
• Pre-operative assessment being incomplete.
• Deficiencies in credentialing and privileging.
  Inadequate supervision of house staff.
  Inconsistent post-operative monitoring procedures.
• Failure to question inappropriate orders.

Risk Reduction Strategies Identified by Hospitals Experiencing These Events

Organizations that experienced complications identified risk reduction strategies. Eighty percent recommended improving staff orientation and training. Other strategies included the following:

• Educating and counseling physicians.
• Expanding on-call coverage, especially in radiology.
• Standardizing procedures across settings of care.
• Revising credentialing and privileging procedures.
• Clearly defining expected channels of communication.
• Revising the competency evaluation process.
• Monitoring consistency of compliance with procedures.
• Implementing a teleradiology program.

Experts' Recommendations

Experts emphasize that direct communication between physicians and other health care providers is very important in preventing complications. There should be more staff education, a more conscientious style of practice, less emphasis on turf issues, and more respect for all of the members of the surgical team, says Dorothy Fogg, R.N. B.S.N., M.A., senior perioperative nursing specialist for the Center for Nursing Practice, Association of PeriOperative Registered Nurses in Denver.

Regarding complications associated with misplacement of tubes or catheters, Mark Malangoni, M.D., a general surgeon at MetroHealth Medical Center in Cleveland, says the correct placement should be confirmed with a test or x-ray. For example, health care providers could check the positioning of a venous catheter with a chest x-ray and the placement of a feeding tube with an abdominal x-ray.

Malangoni, a member of the American College of Surgeons' Pre-Operative and Post-Operative Care Committee, and Fogg recommend that hospitals review their credentialing and privileging procedures to ensure that physicians have proper training and expertise. Fogg says this is especially important in an area like endoscopy where some surgeons may have limited training and experience or where the procedure to be done is relatively new. Those with less experience should work in tandem with someone on staff who has extensive experience in this methodology and has demonstrated competency in the procedure to be performed.

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