A systematic review suggests that, in developed countries, about one in 10 hospital patients experience an adverse event and about 60 percent of these are surgical patients. Fourteen percent of these events are estimated to lead to permanent disability or death, and around 20 percent to temporary disability.

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The most common surgical adverse events include surgical site infection (SSI), pulmonary embolism (PE) and deep vein thrombosis (DVT) or venous thromboembolism (VTE).

There are also serious adverse events, sometimes referred to as ‘never events’ such as wrong site surgery, retained foreign objects and surgical placement of the wrong implant or prosthesis. Although rare, they can cause serious harm to patients and are largely preventable incidents that should not occur if the available preventative measures have been implemented.

Performing safe surgery relies on the ability of surgical team members to combine professional knowledge and technical expertise with non-technical skills, such as communication, teamwork, situational awareness, leadership and decision-making. Communication and teamwork failure is at the core of nearly every medical error and adverse event.

Perioperative harm impacts on patients and the New Zealand health sector in the form of longer hospital stays and repeat procedures. While these complications can never be fully avoided (due to the high-risk nature of some interventions and the underlying health problems of some patients), international experience shows evidence-based interventions that can substantially lower patients’ risks of developing complications.

Interventions such as surgical checklists are now being used in theatres worldwide to reduce incidences of patient harm. Checklists, briefings and debriefings have been derived from other high reliability industries, where errors are not acceptable, such as aviation and nuclear power.

The evidence for the use of checklists, briefings and debriefings, is outlined in the Commission's evidence summary (linked at the bottom of this page) and provides an overview of research and studies undertaken in various hospitals.

Additional evidence and journal articles are available here.

Last updated 13/10/2016