McCahy Philip, Tayyaba Iqra, Andrew Madison, Lim Cheryl Mei Ting, Pornkul Panuwat, Lay Joshua, Chin Calvin Wing Hang, Nguyen Phi, Vinluan Jessele
School of Health Sciences, Monash University, Melbourne, Victoria, Australia.
The Victorian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia.
ANZ J Surg. 2020 May;90(5):725-727. doi: 10.1111/ans.15827. Epub 2020 Mar 19.
The Victorian Audit of Surgical Mortality (VASM) investigates all surgically related deaths in Victoria, Australia, as a surgical educational activity aimed to make surgery safer. Whilst data collected within the audit are regularly reviewed for accuracy, there has never been a review of the data provided from health services.
Two-year death data provided by one Victorian health service were reviewed. Hospital notes for 4 months of each year were analysed to assess patients dying under surgical care. These data were compared to referrals to the VASM over the same period.
Of the 3907 patient deaths recorded, 35.1% were reviewed. During their final admission, 178 (13%) patients underwent a procedure (93 medical and 85 surgical). Only 29.2% of these were recorded in the health service data set. Eighteen patients died under the care of a surgeon without a procedure, meaning that 103 deaths should have been reported to the VASM of which only 55.3% (57/103) were reported.
There were major errors in the health service database resulting in under-reporting of deaths to the VASM which could have education and policy repercussions. For improvements to the safety and quality of health services, it is critical that all deaths are accurately recorded by health services and reported to the relevant bodies with internal verification processes.
维多利亚州外科手术死亡率审计（VASM）对澳大利亚维多利亚州所有与手术相关的死亡病例进行调查，作为一项旨在提高手术安全性的外科教育活动。虽然审计过程中收集的数据会定期审核准确性，但从未对卫生服务机构提供的数据进行过审查。
对维多利亚州一家卫生服务机构提供的两年期死亡数据进行审查。分析每年4个月的医院病历，以评估在手术护理下死亡的患者。将这些数据与同期提交给VASM的转诊数据进行比较。
在记录的3907例患者死亡病例中，35.1%得到了审查。在他们最后一次住院期间，178名（13%）患者接受了手术（93例内科手术和85例外科手术）。其中只有29.2%记录在卫生服务数据集里。18名患者在外科医生护理下未进行手术就死亡，这意味着103例死亡病例本应报告给VASM，但实际仅报告了55.3%（57/103）。
卫生服务数据库存在重大错误，导致向VASM报告的死亡病例漏报，这可能会对教育和政策产生影响。为提高卫生服务的安全性和质量，卫生服务机构准确记录所有死亡病例并通过内部核查程序报告给相关机构至关重要。
