Efforts to improve patient safety have
sparked interest in reporting sentinel and adverse events arising from health care.
Sentinel events are rare but dramatic incidents where medical errors may lead to tangible
harm to patients. These, sometimes referred to as "never
events" , indicate failure of safeguards to protect patients during care
delivery. Foreign body left in during procedure is such an occurrence that reflects
serious process problems. The indicator captures errors relating to the failure to remove
surgical instruments (i.e. needles, knife blades, gauze
swabs) at the end of a procedure. The most common risk factors that might cause retained
bodies after surgery are emergencies, unplanned changes in procedure, changes in the
surgical team during the procedure and patient obesity (Gawande et al., 2003). Preventive measures include counting procedures, a methodical
wound exploration and effective communication among the surgical team.
Adverse events are unintended
incidents caused by health care that could lead to harm to patients. Such complications
can never be fully avoided, given the high-risk nature of some interventions and the
underlying health problems of patients. Thus, in contrast to the sentinel events, isolated
adverse events do not necessarily indicate a patient safety issue. While accidental
puncture or laceration during a surgical procedure is a recognised risk, increased rates
of such complications may indicate system problems, such as inadequate training or
fatigued health staff. Postoperative pulmonary embolism and deep vein thrombosis cause
unnecessary pain and death, but can be prevented through the appropriate use of
anticoagulants and other preventive measures. Sepsis after elective surgery is a severe
complication that can lead to multiple organ dysfunction and death. It usually results
from less severe infections, which should be avoided or properly treated. Many cases of
postoperative sepsis can be prevented through the appropriate use of prophylactic
antibiotics, sterile surgical techniques and good postoperative care.
Figure 5.6.1 Figure 5.6.4 show reported complication
rates related to surgical and medical care. There are considerable differences across
countries for these four indicators. For example, Switzerland has the highest rate for
reported foreign bodies left in during procedure, a very low rate for postoperative
pulmonary embolism or deep vein thrombosis, and the lowest rate for postoperative sepsis.
A similar variance in indicator results can be found for Canada, Spain and France. Some
countries have consistently higher (Australia, New Zealand) or lower reporting rates
Differences in procedural or
postoperative patient safety indicators may reflect differences in recording and reporting
practices rather than safety of care. In countries where documentation and hospital
billing are not directly related, hospitals and physicians have less incentive to report
diagnoses accurately and completely. Although there may be reservations whether the
current results accurately reflect patient safety performance at the national level and
are internationally comparable, these indicators show that numerous patients certainly
have been affected by patient safety events. International efforts to harmonise
documentation and data systems, and the results of ongoing validation studies, will
provide more information on validity and reliability of patient safety measures based on
administrative hospital data in the future.
Definition and comparability
See Indicator 5.5
"Obstetric trauma" for definition, source and methodology
underlying the patient safety rates. All procedural or postoperative complications are
defined as the number of discharges with ICD codes for complication in any secondary
diagnosis field, divided by the total number of discharges (medical and surgical or
surgical only) for patients aged 15 and older. The rates have been age-sex
standardised, apart from postoperative sepsis rate. This is due to the use of modified
exclusion criteria within the algorithm for the calculation of this indicator. In
addition, the patient safety rates have been adjusted by the average number of
secondary diagnoses (SDx) (Drösler et al., 2011) in
order to improve inter-country comparability. Despite this adjustment, the results for
the two countries (Finland and Italy) that are reporting less than 1.5 diagnoses per
record may be under-estimated.
Other differences in data
reporting across countries may influence the calculated rates of patient safety
indicators. These include differences in coding practice, coding rules (e.g. definition of principal and secondary diagnoses),
coding for billing purposes and the use of diagnosis type markers (e.g.
"present at admission" ).