Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome.

Objective: To evaluate patient safety in an emergency surgical unit using process and outcome measures in parallel.

Background: Patient harm from errors in care is common in modern surgical practice. Measurement of the problem is essential to any solution, but current methods of evaluating patient harm are either impractical or inadequate. We have therefore analyzed compliance with safety-relevant care processes, with the aim of developing a process-based system for evaluating ward safety.

Methods: Adverse events (AE), potential adverse events (PAE), and 7 safety-relevant processes were measured on a 38-bed surgical emergency unit over a 16-week period. AE, PAE, and process measures were studied by prospective direct observation in large convenience samples, using objective measures. Possible influences on AE and PAE risk were analyzed.

Results: Compliance with the 7 processes studied ranged from 23% to 89%. The AE and PAE rates were 11.9% and 13.8% in a 63% sample of admissions (n = 607). Length of stay was significantly associated with both AE (P < 0.001) and PAE (P < 0.001). Having an operation was also associated with AE (P = 0.001) but not with PAE. No other factors appeared to influence AE/PAE rates. Delays were the commonest causes of both AE and PAE.

Conclusions: Compliance with individual care processes on a ward with average levels of patient harm is poor. Length of hospital stay increases the risk of both AE and PAE, suggesting a system defect. A bundle of care processes may be useful for monitoring safety improvement.