GS20 *ADVERSE EVENTS IN GENERAL SURGERY

Background:   The rate of adverse events occurring in Australian hospitals is reported to be up to 12–17%. Adverse events need to be identified, reported and responded to if the system of health care is to be improved. The purpose of this study was to determine the rate and nature of adverse events (unintentional harm arising as a result of healthcare) in general surgery in the Geelong Hospital. Method:   A review was conducted of adverse events in the hospital incident reporting system (Riskman) and general surgical audits between 2004 and 2008. Adverse events were categorised according to severity (1–4) and the hospital response to these events noted. Results:   There were 888 adverse events arising in 12801 general surgical admissions (6.93%). Their severity assessment codes (SAC) were: catastrophic (0.15%),; major (0.40%),; moderate (2.22%),; and minor (4.30). Some of the complications reported in surgical audits were also adverse events, the major ones being mortality (0.74%), unplanned reoperation (1.27%) and unplanned readmission (1.46%). Identification and tracking of these enabled implementation of system changes. These included a colorectal outcome reporting, PreVENT program (for DVT prophylaxis), review of colonoscopy initiatives, bedside tracheostomy care, and an electronic system to respond to pathology results (TR3). Conclusion:   The adverse event rates occurring in general surgery at the Geelong Hospital were lower than those previously reported in the literature and may reflect a general improvement in the quality of care during the last decade if these rates are applicable to other hospitals. The hospital response to adverse events has resulted in significant sustainable system changes.