title: Impact of cardiac intraoperative precursor events on adverse outcomes.
abstract: BACKGROUND
  Although extensive study has been directed at the influence of patient factors and comorbidities on cardiac surgical outcomes, less attention has been focused on process. We sought to examine the relationship between intraoperative precursor events (those events that precede and are requisite for the occurrence of an adverse event) and adverse outcomes themselves.
  
  
  METHODS
  Anonymous, prospectively collected intraoperative data was merged with database outcomes for 450 patients undergoing major adult cardiac operations. Precursor events were categorized by type, person most affected, severity, and compensation. Number and categories of precursor events were analyzed as predictors of a composite outcome combining death or near miss complications (DNM), using logistic regression.
  
  
  RESULTS
  Precursor events occurred more frequently in cases with a DNM outcome than in those with no adverse event (2.7 +/- 2.4 vs 2.0 +/- 2.3/procedure, P = .005). After adjustment for other patient characteristics, the number of precursor events remained an independent predictor of DNM (RR, 1.14 per event [1.04 to 1.24]). Of 990 events, 35.6% related to management, 28.8% were technical, and 22.8% were environment-related. The surgeon was most affected in 40.8%, and 16.5% were of major severity. When categories of precursor events were analyzed, major severity events and those most affecting the surgeon were independent predictors of DNM.
  
  
  CONCLUSIONS
  More detailed study of process in complex operations may lead to improved quality of care and patient safety. Special attention must be paid particularly to high risk patients and high risk precursor events.
authors.affiliation: Maritime Heart Centre, Halifax, NS, Canada.
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Wong
authors.forename: David F
authors.initials: DF
authors.lastname: Torchiana
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Vander Salm
authors.forename: Arvind K
authors.initials: AK
authors.lastname: Agnihotri
authors.forename: Richard M J
authors.initials: RM
authors.lastname: Bohmer
authors.forename: Imtiaz S
authors.initials: IS
authors.lastname: Ali
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D007431:Intraoperative Complications; D007432:Intraoperative Period; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012307:Risk Factors