Clinical events reported by surgeons assessing their peers

Area of Science:

• Surgical Quality Improvement
• Patient Safety Research
• Clinical Audit

Background:

• External peer review of all surgical deaths in Queensland, Australia is standard practice.
• Clinical events associated with surgical mortality are systematically recorded.

Purpose of the Study:

• To classify the types of clinical events occurring in deceased surgical patients.
• To identify patterns and causes of adverse events in surgical mortality.

Main Methods:

• Analysis of deaths reported to the Queensland Audit of Surgical Mortality from 2007 to 2013.
• Peer surgeons assessed cases to determine the occurrence and nature of clinical events.
• Focus on the most serious clinical event identified for each patient.

Main Results:

• 4,816 surgical deaths were reviewed by peer surgeons.
• 70.7% of patients experienced no identifiable clinical event.
• 58% of identified events were deemed preventable, with less than 10% classified as severe.
• Top event categories included patient assessment (34.5%), suboptimal therapy (15.3%), and delays (15.1%).

Conclusions:

• Peer review of surgical mortality effectively identifies preventable clinical events.
• Findings offer opportunities to enhance clinical decision-making and surgical care.
• Feedback mechanisms from peer review can improve patient safety and quality of care.