Rey-Conde Therese, Wysocki Arkadiusz P, North John B, Allen Jennifer, Ware Robert S, Watters David A
Division of Research, Audit and Academic Surgery, Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, 7476, East Brisbane, Brisbane, Queensland, 4169, Australia.
Department of Surgery, Logan Hospital, Logan City, Queensland, Australia.
Am J Surg. 2016 Oct;212(4):748-754. doi: 10.1016/j.amjsurg.2016.01.027. Epub 2016 Mar 23.
All surgical deaths in Queensland, Australia are reviewed by external surgeon peers, and clinical events are recorded. The study objective was to classify clinical events in surgical patients who died.
Deaths notified to the Queensland Audit of Surgical Mortality between 2007 and 2013 were assessed by surgeons' peers who decided whether a clinical event occurred. The most serious clinical event per patient was analyzed.
Peer surgeons reviewed 4,816 deaths. Most patients (70.7%) had no clinical event. Events were preventable in 58% of patients and less than 1 in 10 events was severe. The most frequent events were classified as patient assessment (34.5%), suboptimal therapy (15.3%), and delays (15.1%).
Peer review of all surgical deaths identifies preventable clinical events and provides opportunities to improve decision making, better therapy and reduce delay in implementing appropriate surgical care. Review feedback to surgeons and other stakeholders should improve patient safety and quality.
澳大利亚昆士兰州的所有外科手术死亡病例均由外部外科同行进行审查，并记录临床事件。本研究的目的是对死亡的外科手术患者的临床事件进行分类。
2007年至2013年间通知昆士兰外科死亡率审计的死亡病例由外科同行进行评估，他们决定是否发生了临床事件。分析了每位患者最严重的临床事件。
同行外科医生审查了4816例死亡病例。大多数患者（70.7%）没有临床事件。58%的患者的事件是可预防的，每10起事件中严重事件不到1起。最常见的事件分类为患者评估（34.5%）、治疗欠佳（15.3%）和延误（15.1%）。
对所有外科手术死亡病例进行同行审查可识别可预防的临床事件，并提供改进决策、优化治疗和减少实施适当外科护理延误的机会。向外科医生和其他利益相关者提供审查反馈应可提高患者安全性和质量。
