Frequency and content analysis of adverse event reports in surgical centers: a cross-sectional study.
Ítalo Lennon Sales de Almeida, Ana Paula Agostinho Alencar, Vanessa de Brito Poveda and 1 others
PMID 40105529WHAT IT FOUND
Surgical centers recorded 163 adverse event reports among 9,253 notifications; pressure injuries, burns, surgical site infection and organ damage were most frequent, and 44 free-text descriptions were blank.
Key findings
01Only 163 of 9,253 adverse event notifications were from surgical centers over a period when 151,293 surgical procedures were performed, and 57.1% of those notifications indicated mild harm.
02Pressure injury was the most frequent reported adverse event, followed by burns, surgical site infection and organ damage, and 16 never events were identified.
0344 of the 163 notifications left the free-text description blank, leaving 119 reports for qualitative content analysis.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study only analysed reports already entered into Notivisa, so adverse events that were not reported are missing. Only 163 surgical-centre reports were analysed, and the authors state this limits generalisation. 44 of the 163 free-text descriptions were blank, so the qualitative analysis used only 119 reports. The cross-sectional design cannot show whether prevention measures reduced events, and the researchers did not interview reporting professionals.
The easy way to misread this
Do not read 163 notifications as proof that surgical adverse events are rare. The authors state that underreporting limits recognition of the real scenario, and 44 of 163 free-text descriptions were blank.