Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review
Adverse events occur commonly in the operating room (OR) and often contribute to morbidity, mortality, and increased healthcare spending. Validated frameworks to measure and report postoperative outcomes have long existed to facilitate exchanges of structured information pertaining to postoperative complication rates in order to improve patient safety. However, systematic evidence regarding measurement and reporting of intraoperative adverse events (iAE) is still lacking.
We searched Ovid Medline, Embase, and Cochrane databases for articles published up to June 2016 that measured and reported iAE. We presented the terms and definitions used to describe iAE. We identified the types of reported iAE and summarized them into discrete categories. We reported frequencies of iAE by detection methods.
Of the 47 included studies, 30 were cross-sectional, 14 were case-series, and 3 were cohort studies. The studies used 16 different terms and 22 unique definitions to describe 74 types of iAE. Frequencies of iAE appeared to vary depending on the detection methods, with higher numbers reported when direct observation in the OR was used to detect iAE. Twenty studies assessed severity of iAE, which were mostly based on whether they resulted in postoperative outcomes.
This study systematically reviewed the current evidence on prevalence and characteristics of iAE that were detected by direct observation, reviews of patient charts, administrative data and incident reports, and surveys and interviews of healthcare providers. Our findings suggest that direct observation method has the most potential to identify and characterize iAE in detail.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 12.Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions. Cochrane Collaboration, OxfordGoogle Scholar
- 14.National Institute of Health (2017) National institute of health quality assessment tool for observational cohort and cross-sectional studies. Retrieved from https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools
- 22.Ugur E, Kara S, Yildirim S et al (2016) Medical errors and patient safety in the operating room. J Pak Med Assoc 66:593–597Google Scholar
- 49.Heideveld-Chevalking AJ, Calsbeek H, Damen J et al (2014) The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 ‘near-misses’ and adverse events. Patient Saf Surg 8:46Google Scholar
- 52.Wanzel KR, Jamieson CG, Bohnen JM (2000) Complications on a general surgery service: incidence and reporting. Can J Surg 43:113–117Google Scholar
- 60.World Health Organization (2005) WHO draft guidelines for adverse event reporting and learning systems. WHO Press, Geneva, SwitzelandGoogle Scholar
- 61.Kohn L, Corrigan J, Donaldson M (2000) To err is human: building a safer health system. National Academies Press, Washington (DC)Google Scholar
- 63.Jung J, Jüni P, Lebovic G, et al. (2018) First year analysis of the operating room black box study, Unpublished workGoogle Scholar