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Mortality associated with surgery: a case review study.

K Gannon1

  • 1The Royal London Hospital Medical College, The School of Occupational Therapy, London, UK.

The International Journal of Risk & Safety in Medicine
|March 21, 2013
PubMed
Summary
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This review of 16 surgical deaths from 1982-1986 found common factors like poor pre-operative assessment and lack of experience contributed to patient mortality. Improving training and communication is crucial for surgical safety.

Area of Science:

  • Medical Science
  • Surgical Safety
  • Patient Outcomes

Background:

  • Analysis of anonymous case records from a UK medical protection organization (1982-1986).
  • Focus on deaths associated with general surgical procedures.

Purpose of the Study:

  • To identify common contributing factors in patient deaths during general surgery.
  • To compare findings with the National Confidential Inquiry into Perioperative Deaths.
  • To propose improvements in surgical training and practice.

Main Methods:

  • Review of 16 anonymous case records involving patient deaths.
  • Analysis of procedural types, patient demographics, and contributing factors.
  • Qualitative assessment of pre-operative, intra-operative, and post-operative care.

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Main Results:

  • Majority of deaths occurred during elective procedures in relatively young patients (average age 48.4).
  • Key contributing factors identified: inadequate pre-operative assessment (4 cases), inadequate post-operative management (3 cases), and lack of experience (3 cases).
  • Varied procedures and proximate causes of death, but common systemic issues identified.

Conclusions:

  • Inadequate pre-operative assessment and insufficient experience are significant risks in general surgery.
  • Enhanced training, improved communication, and critical incident monitoring are recommended to improve surgical patient safety.
  • Findings align with broader national inquiries into perioperative mortality.