• Nicholas R A Symons, Alex M Almoudaris, Kamal Nagpal, Charles A Vincent, and Krishna Moorthy.
• Clinical Safety Research Unit, Department of Surgery and Cancer, Imperial College London, London, UK. n.symons@imperial.ac.uk
• Ann. Surg.. 2013 Jan 1;257(1):1-5.

ObjectiveTo investigate the nature of process failures in postoperative care, to assess their frequency and preventability, and to explore their relationship to adverse events.BackgroundAdverse events are common and are frequently caused by failures in the process of care. These processes are often evaluated independently using clinical audit. There is little understanding of process failures in terms of their overall frequency, relative risk, and cumulative effect on the surgical patient.MethodsPatients were observed daily from the first postoperative day until discharge by an independent surgeon. Field notes on the circumstances surrounding any nonroutine or atypical event were recorded. Field notes were assessed by 2 surgeons to identify failures in the process of care. Preventability, the degree of harm caused to the patient, and the underlying etiology of process failures were evaluated by 2 independent surgeons.ResultsFifty patients undergoing major elective general surgery were observed for a total of 659 days of postoperative care. A total of 256 process failures were identified, of which 85% were preventable and 51% directly led to patient harm. Process failures occurred in all aspects of care, the most frequent being medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. Process failures accounted for 57% of all preventable adverse events. Communication failures and delays were the main etiologies, leading to 54% of process failures.ConclusionsProcess failures are common in postoperative care, are highly preventable, and frequently cause harm to patients. Interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce hospital stay.

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