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Title of Journal: International Orthopaedics SICOT

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Abbravation: International Orthopaedics

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Springer Berlin Heidelberg

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DOI

10.1007/bf02070430

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1432-5195

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Incidence and preventability of adverse events in

Authors: Shanmuganathan Rajasekaran Srikesh Ravi Siddharth N Aiyer
Publish Date: 2016/09/01
Volume: 40, Issue: 11, Pages: 2233-2238
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Abstract

Four thousand nine hundred and six consecutive inpatient admissions over six months in an orthopaedic unit were prospectively analysed The total indoor patient capacity was segregated into 25bed units each and AEs were recorded on a daily basis by two observers Each event was assessed by allotting a causation score 1–6 with a score of ≥ 4 implying a systemic/individual failure of healthcare provision A preventability score 1–6 was allotted and scores ≥ 4 were considered to be preventableFour hundred and sixtyseven patients 95  suffered a total of 529 AEs including 127 readmissions 49 patients suffering multiple events Three hundred and thirtythree 629  events had a causation score of ≥ 4 indicating a failure of healthcare delivery systems Three hundred and one 568  events could have been prevented with better regulation and adherence to management protocols Hospitalacquired infections were the most common event with surgicalsite infection in 102 cases 192 and 2  overall and catheterassociated urinary tract infections noted in 45 85  patients Medical events included seven deep vein thrombosis two pulmonary embolisms five myocardial infarctions and one stroke AEs occurred 563  in the ward 43  in the intensive care unit ICU 62  in the emergency room and 90  in the operating theatreAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards

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