Detecting and Reporting Errors, Complications, and Adverse Events

Two landmark reports, “To Err Is Human” and “Crossing the Quality Chasm,” released by the Institute of Medicine in the early 2000s, estimated that between 44,000 and 98,000 patients died every year in the United States because of medical errors. The same reports highlighted that efforts aimed at measuring the quality of care were insufficient, and that medical errors were often caused by flawed systems from a patient safety perspective (Havens DH, Boroughs L, J Pediatr Health Care 14:77–80, 2000; Institute of Medicine (US) Committee on Quality of Health Care in America, Crossing the quality chasm: a new health system for the 21st century. National Academies Press (US), Washington, 2001). Applying these healthcare statistics to modern professional aviation equates to nearly 200 jumbo jets crashing every year, or one Boeing 747 airplane crashing every other day (Stahel, Patient Saf Surg 2:21, 2008). This staggering insight led to the rapid rise in patient safety as a field in healthcare and the launch of many initiatives worldwide to improve patient safety, such as the “100,000 lives campaign” by the Institute for Healthcare Improvement (IHI) in 2004. This chapter will describe the evolution of adverse event and error detection-and-reporting systems in surgery, as well as classification tools that allow for risk adjustment.