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Karl Y. Bilimoria, MD, MS; Thomas E. Kmiecik, PhD; Debra A. DaRosa, PhD; Amy Halverson, MD; Mark K. Eskandari, MD; Richard H. Bell Jr, MD; Nathaniel J. Soper, MD; Jeffrey D. Wayne, MD

Arch Surg. 2009;144(4):305-311.

Objectives  To design a Web-based system to track adverse and near-miss events, to establish an automated method to identify patterns of events, and to assess the adverse event reporting behavior of physicians.

Design  A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness.

Setting  A metropolitan tertiary care center.

Main Outcome Measures  Identification of adverse event patterns and completeness of reporting.

Results  From September 2005 to August 2007, 15 524 surgical patients were reported including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25% of complications and 42% of inpatient deaths were reported. A total of 75.2% of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful.

Conclusions  We have developed a user-friendly Web-based system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities.

Author Affiliations: Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (Drs Bilimoria, Kmiecik, DaRosa, Halverson, Eskandari, Soper, and Wayne); and the American Board of Surgery, Philadelphia, Pennsylvania (Dr Bell).

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