Objective: 

While errors can harm patients they remain poorly studied. This study characterized errors in the care of surgical patients and examined the association of errors with morbidity and mortality.

Summary Background Data: 

Errors have been reported to cause less than 10% or greater than 60% of adverse events. Such discordant results underscore the need for further exploration of the relationship between error and adverse events.

Methods: 

Patients with operations performed at a single institution and abstracted into the American College of Surgeons National Surgical Quality Improvement Program from January 1, 2018 - December 31, 2018 were examined. This matched case control study comprised cases who experienced a postoperative morbidity or mortality. Controls included patients without morbidity or mortality, matched 2:1 using age (±10 y), sex, and CPT Group. Two faculty surgeons independently reviewed records for each case and control patient to identify diagnostic, technical, judgment, medication, system, or omission errors. A conditional multivariable logistic regression model examined the association between error and morbidity.

Results: 

Of 1899 patients, 170 were defined as cases who experienced a morbidity or mortality. The majority of cases (n=93; 55%) had at least one error; of the 329 matched control patients, 112 had at least one error (34%). Technical errors occurred most often among both cases (40%) and controls (23%). Logistic regression demonstrated a strong independent relationship between error and morbidity (OR 2.67, 95% CI 1.64–4.35, P<0.001).

Conclusions: 

Errors in surgical care were associated with postoperative morbidity. Reducing errors requires measurement of errors.

中文翻译：

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手术错误：病例对照研究

客观的： 

虽然错误会伤害患者，但对他们的研究仍然很少。本研究描述了手术患者护理中的错误，并检查了错误与发病率和死亡率之间的关系。

摘要背景数据： 

据报道，错误导致的不良事件少于 10% 或多于 60%。这种不一致的结果强调需要进一步探索错误与不良事件之间的关系。

方法： 

对 2018 年 1 月 1 日至 2018 年 12 月 31 日在单一机构进行手术并被纳入美国外科医师学会国家外科质量改进计划的患者进行了检查。这项匹配的病例对照研究包括经历过术后发病率或死亡率的病例。对照组包括没有发病率或死亡率的患者，使用年龄（±10 岁）、性别和 CPT 组按 2:1 匹配。两名教员外科医生独立审查了每个病例和对照患者的记录，以确定诊断、技术、判断、药物、系统或遗漏错误。条件多变量逻辑回归模型检查了错误和发病率之间的关联。

结果： 

在 1899 名患者中，有 170 名被定义为发生发病或死亡的病例。大多数案例（n=93；55%）至少有一个错误；在 329 名匹配的对照患者中，112 名至少有一处错误 (34%)。技术错误最常发生在病例 (40%) 和对照 (23%) 中。逻辑回归表明错误与发病率之间存在很强的独立关系（OR 2.67，95% CI 1.64–4.35，P <0.001）。

结论： 

手术护理错误与术后并发症有关。减少错误需要测量错误。