Joint Commission Sentinel Event Alert
Operative and postoperative complications
• The Joint Commission reviewed 64 cases of operative and postoperative complications.
• All of the cases occurred in acute care hospitals.
• Cases directly related to medication errors or to administration of anesthesia were not included.
• 58% of the complications occurred during the postoperative procedure period, 23% during the intraoperative procedures, 13% during post-anesthesia recovery, and 6% during anesthesia induction.
• The types of procedures most frequently associated with these reported complications included interventional imaging and/or endoscopy, tube or catheter insertion, open abdominal surgery, head and neck surgery, orthopedic surgery, and thoracic surgery.
• The most frequent complications by type of procedure included:
— naso-gastric/feeding tube insertion into the trachea or a bronchus;
— massive fluid overload from absorption of irrigation fluids during genito-urinary/gyneco- logical procedures;
— open orthopedic procedures associated with acute respiratory failure, including cardiac arrest in the operating room;
— endoscopic procedures (including nongas-trointestinal procedures) with perforation of adjacent organs; liver lacerations among the most frequent complications of abdominal and thoracic endoscopic surgery;
— central venous catheter insertion into an artery;
— imaging-directed percutaneous biopsy or tube placement resulting in liver laceration, peritonitis, or respiratory arrest while temporarily off prescribed oxygen;
— burns from electrocautery used with a flammable prep solution.
Source: Joint Commission on Accreditation of Healthcare Organizations. Operative and post-operative complications: Lessons for the future. Sentinel Event Alert 2000; 12. Web site: www.jcaho.org.
For more information on reducing errors in same-day surgery, contact:
• Richard Croteau, MD, Executive Director, Strategic Initiatives, Joint Commission on Accreditation of Healthcare Organizations. E-mail: [email protected].
• Ann Geier, RN, MS, CNOR, Chief Operating Officer, Medicus Surgery Center, P.O. Box 1886, 107 Professional Court, Anderson, SC 29622-1886. Telephone: (864) 716-7911. Fax: (864) 716-7965. E-mail: [email protected].
• Susan Kizirian, MBA, Executive Director, Southeastern Surgery Center, 2000 Center Point Blvd., Tallahassee, FL 32308. Telephone: (850) 309-0500. E-mail: [email protected].
• Vicki Sullivan, RN, CNOR, Administrative Director, Quad City Ambulatory Surgery Center, 520 Valley View Drive, Moline, IL 61265. Telephone: (309) 762-1952. Fax: (309) 762-3642. E-mail: [email protected].
The Sentinel Event Alert issued by the Joint Commission on Accreditation of Healthcare Organizations can be found on the agency’s Web site at www.jcaho.org. Click on "for health care organizations and professionals," then "sentinel events," then "sentinel event alert," and select the Feb. 4, 2000, bulletin titled "Operative and Post-Operative Complications: Lessons for the Future." To obtain the latest copy of Sentinel Event Alert by fax, call the Joint Commission’s fax on demand line at (630) 792-3885. Press 4.
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