AHRQ Patient Safety Network ► Unplanned return to theater: a quality of care and risk management index?

AHRQ Patient Safety Network

Half of cases involving an unplanned return to OR after surgery were judged to represent a preventable complication.Orthop Traumatol Surg Res. 2015;101:399-403.

Unplanned return to theater: a quality of care and risk management index?

Pujol N, Merrer J, Lemaire B, et al. Orthop Traumatol Surg Res. 2015;101:399-403.

Trigger tools are a useful method to screen for adverse events. To determine whether unplanned return to surgery could be utilized as a trigger for detecting errors, this study assessed rates of such incidents in an orthopedic and traumatologic surgery department. Using an approach similar to prior studies of delayed diagnosis, researchers examined a retrospective case series of orthopedic and trauma surgeries in which a revision procedure occurred. They found a relatively low incidence of unplanned return to surgery, but their clinical review indicated that half of such cases represented preventable complications. The authors advocate for a registry of unplanned return surgeries as a patient safety improvement strategy.

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