title: Surgical adverse outcome reporting as part of routine clinical care.
abstract: BACKGROUND
  In The Netherlands, health professionals have created a doctor-driven standardised system to report and analyse adverse outcomes (AO). The aim is to improve healthcare by learning from past experiences. The key elements of this system are (1) an unequivocal definition of an adverse outcome, (2) appropriate contextual information and (3) a three-dimensional hierarchical classification system.
  
  
  OBJECTIVE
  First, to assess whether routine doctor-driven AO reporting is feasible. Second, to investigate how doctors can learn from AO reporting and analysis to improve the quality of care.
  
  
  METHODS
  Feasibility was assessed by how well doctors reported AO in the surgical department of a Dutch university hospital over a period of 9 years. AO incidence was analysed per patient subgroup and over time, in a time-trend analysis of three equal 3-year periods. AO were analysed case by case and statistically, to learn lessons from past events.
  
  
  RESULTS
  In 19,907 surgical admissions, 9189 AOs were reported: one or more AO in 18.2% of admissions. On average, 55 lessons were learnt each year (in 4.3% of AO). More AO were reported in P3 than P1 (OR 1.39 (1.23-1.57)). Although minor AO increased, fatal AO decreased over time (OR 0.59 (0.45-0.77)).
  
  
  CONCLUSIONS
  Doctor-driven AO reporting is shown to be feasible. Lessons can be learnt from case-by-case analyses of individual AO, as well as by statistical analysis of AO groups and subgroups (illustrated by time-trend analysis), thus contributing to the improvement of the quality of care. Moreover, by standardising AO reporting, data can be compared across departments or hospitals, to generate (confidential) mirror information for professionals cooperating in a peer-review setting.
authors.affiliation: Department of Medical Decision Making, Leiden University Medical Centre, The Netherlands. j.kievit@lumc.nl
authors.forename: J
authors.initials: J
authors.lastname: Kievit
authors.forename: M
authors.initials: M
authors.lastname: Krukerink
authors.forename: P J
authors.initials: PJ
authors.lastname: Marang-van de Mheen
mesh_terms: D000328:Adult; D000368:Aged; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D019221:Mandatory Reporting; D008875:Middle Aged; D009426:Netherlands; D017063:Outcome Assessment, Health Care / Q000458:organization & administration; D011785:Quality Assurance, Health Care / Q000458:organization & administration; D013514:Surgical Procedures, Operative / Q000009:adverse effects*; D055815:Young Adult