Prevalence and avoidability of surgical adverse events in a teaching hospital in Brazil.
Josemar Batista, Elaine Drehmer de Almeida Cruz, Francine Taporosky Alpendre and 3 others
PMID 31596404WHAT IT FOUND
In records reviewed at a Brazilian teaching hospital, 42 surgical patients had at least one adverse event, totaling 60 events; 90% were judged preventable, 50% were healthcare-associated infections, and 90% were mild or moderate.
Key findings
0142 surgical patients had at least one adverse event; 26.2% had more than one event, totaling 60 events, and 90% of the events were judged preventable.
02Healthcare-associated infection accounted for 50% of surgical adverse events, surgical site infection accounted for 30%, and 90% of events were classified as mild or moderate.
03Outpatient return records contributed to 52.4% of cases, and 2 patients were readmitted as a result of an adverse event.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study was done in one teaching hospital in Brazil, so the rates may not apply to other hospitals or countries. Adverse events were found by reviewing medical records, and records were incomplete, illegible or erased, so some events may have been missed. The paper refers to a flowchart for record selection and prevalence, but the flowchart is not included in the supplied text, so the exact number analysed cannot be confirmed. Deaths outside the hospital or in another institution could not be investigated, so fatal events may be undercounted. The study did not test an intervention, so it cannot show that any specific change in care would prevent adverse events.
The easy way to misread this
Do not read the 90% preventable figure as proof that any specific nursing or surgical intervention would prevent these events. This was a retrospective record review without a control group, so it cannot show what changes would reduce adverse events.