Accepte

ReprintStudies,Universi(NUTOversity, 7E-mail:

0039-60

� 2014

http://d

1106

Detection of medical errors in kidneytransplantation: A pilot studycomparing proactive cliniciandebriefings to a hospital-wide incidentreporting systemLisa M. McElroy, MD,a,b Amna Daud, MD, MPH,b Brittany Lapin, MPH,b Olivia Ross, MBA,b

Donna M. Woods, PhD,a,b Anton I. Skaro, MD, PhD,b Jane L. Holl, MD, MPH,a,b andDaniela P. Ladner, MD, MPH,a,b Chicago, IL

Background. Rates of medical errors and adverse events remain high for patients who undergo kidneytransplantation; they are particularly vulnerable because of the complexity of their disease and the kidneytransplantation procedure. Although institutional incident-reporting systems are used in hospitalsaround the country, they often fail to capture a substantial proportion of medical errors. The goal of thisstudy was to assess the ability of a proactive, web-based clinician safety debriefing to augment theinformation about medical errors and adverse events obtained via traditional incident reporting systems.Methods. Debriefings were sent to all individuals listed on operating room personnel reports for kidneytransplantation surgeries between April 2010 and April 2011, and incident reports were collected for thesame time period. The World Health Organization International Classification for Patient Safety wasused to classify all issues reported.Results. A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36contributing factors). Compared with incident reports, more attending physicians completed thedebriefings (32.0 vs 3.5%).Discussion. The use of a proactive, web-based debriefing to augment an incident reporting system inassessing safety risks in kidney transplantation demonstrated increased information, more perspectives ofa single safety issue, and increased breadth of participants. (Surgery 2014;156:1106-15.)

From the Center for Healthcare Studies,a Institute for Public Health and Medicine, and NorthwesternUniversity Transplant Outcomes Research Collaborative (NUTORC),b Comprehensive Transplant Center,Feinberg School of Medicine, Northwestern University, Chicago, IL

MEDICAL ERRORS ARE DEFINED as mistakes made in thedelivery of care that result in---or have the potentialto result in---harm to a patient. Adverse events,defined as untoward and usually unanticipatedoutcomes that occur in association with healthcare, increase readmission rates, negatively affectthe quality of life of the recipient, and adversely

d for publication May 8, 2014.

requests: Lisa M. McElroy, MD, Center for HealthcareInstitute for Public Health and Medicine, Northwesternty Transplant Outcomes Research CollaborativeRC), Feinberg School of Medicine, Northwestern Uni-50 N. Lakeshore Drive, 10th floor, Chicago, IL 60611.lisa.mcelroy@northwestern.edu; dladner@nmh.org.

60/$ - see front matter

Elsevier Inc. All rights reserved.

x.doi.org/10.1016/j.surg.2014.05.013

SURGERY

affect patient outcomes.1 Patients who undergokidney transplantation are particularly vulnerableto the consequences of medical errors and adverseevents attributed to the polymorbid nature of end-stage renal disease and the complexity of the kid-ney transplantation procedure.2

Efforts to reduce the rates of medical errors andadverse events in patients who undergo kidneytransplantation have been in part stimulated byhigh-profile events, including the removal of thewrong donor kidney, the accidental discarding of akidney from a living donor during turn-over of theoperating room from the donor surgery to therecipient surgery, or disease transmission fromdonor to recipient.3-7 However, for every medicalerror that reaches the patient and causes patientharm, hundreds of near misses and thousands ofmedical errors occur that do not cause patient

SurgeryVolume 156, Number 5

McElroy et al 1107

harm.8,9 Therefore, examining near misses andmedical errors presents ample opportunity forimprovement of delivery of care in an effort toreduce the rate of adverse events, which remainunacceptably high for transplant donors andrecipients.10,11

The Institute of Medicine report on patientsafety, To Err is Human, which brought increasedattention to the importance of medical error pre-vention, called for the institution of voluntary re-porting programs within hospitals to capturemedical errors and adverse events and also provideinformation that leads to new knowledge andimproved patient safety.12,13 As a result, institu-tional incident reporting systems have beenincreasingly implemented in hospitals throughoutthe country.14-18 However, incident reporting sys-tems often fail to capture a substantial proportionof medical errors, particularly those that do notlead to adverse events. This is attributed to thefact that they are voluntary and not actively soli-cited, often time consuming to complete, and pri-marily aimed at nursing staff rather than at theentire clinical care team.19-22

In an effort to augment the informationcollected on medical errors and adverse eventsvia incident reporting systems, we developed andimplemented a proactive web-based safety de-briefing tool for clinicians and staff involved intransplant surgery. We categorized the informa-tion gathered via debriefing responses using theWorld Health Organization (WHO) Interna-tional Classification for Patient Safety andcompared it with the information obtainedthrough the incident reporting system.23 We hy-pothesized that implementation of a proactive,web-based safety debriefing would result inincreased knowledge of safety vulnerabilities inkidney transplantation.

METHODS

Setting. Our study was conducted in a large,urban and tertiary referral transplantation centerbetween April 1, 2010, and April 1, 2011. Incidentreports were obtained from the NorthwesternEvent Tracking System, and debriefing responseswere solicited using the Web-based NorthwesternTransplant Patient Safety Debriefing Tool.24

Approval was obtained from the NorthwesternUniversity Institutional Review Board before datacollection.

Incident reports. The Northwestern EventTracking System is a hospital-wide electronic

incident reporting system designed to captureinformation about medical errors and adverseevents with the goal to improve patient care(online Supplementary Fig. 1). Hospital em-ployees are encouraged to report any events thatmay have negatively affected patient care, as wellas any situations that occurred during hospitaliza-tion with the potential to cause patient harm. Allinformation captured through Northwestern EventTracking System is treated confidentially.

Debriefings. An interdisciplinary team of pa-tient safety experts and transplant clinicianscreated a web-based safety debriefing tool de-signed to obtain information from cliniciansabout the safety of delivery of care towards trans-plant patients (online Supplementary Fig 2).24-26

The debriefing tool solicits comments on all pa-tient safety–related concerns or events encoun-tered during the kidney transplantationprocedure through several thematic promptsand four open ended questions, allowing forfurther elaboration when any of the initial the-matic areas of care were designated asproblematic.

The thematic prompts were: Communicationwith the Patient and the Family, Inter-ProviderCommunication, Distractions, Care Coordination,Patient Identification, Information Technology,Access to Necessary Clinical Data, Patient Educa-tion/Teaching, Medications, Coordination withCare Facilities/Hotel, Discharge Planning,Discharge Instructions, Appointment Scheduling,Blood/Transfusions, Labs/Studies, Equipment/Physical Environment, Patient Vitals Monitoring,Non-specific Adverse Events, Bed Availability/Staff-ing, and Transitions/Transportation/Hand-offs.

The 4 questions were: (1) Did you encounterother issues or barriers that made your work moredifficult? (2) Did you follow up on issues describedin this debriefing? How? (3) Did you have sugges-tions to address the issues described in thisdebriefing? (4) How would you improve patientsafety?

A convenience sample of clinicians involved inkidney transplant donor and recipient surgerieswas chosen for web-based debriefing. Within24 hours of completion of selected surgeries,e-mails were sent to all individuals listed in theoperating room nursing personnel report request-ing participation via a hyperlink to the debriefing.Participants provide consent electronically andtheir responses are gathered anonymously andanalyzed in aggregate. Nonrespondents received

SurgeryNovember 2014

1108 McElroy et al

reminder e-mails at 24 and 48 hours after theinitial e-mail request.

The International Classification for PatientSafety (ICPS). All reported issues listed in inci-dent reports and debriefing responses wereclassified using the recently developed WorldHealth Organization (WHO) ICPS. The ICPSwas created via a Delphi process to facilitatecomparison of patient safety research findingsbetween institutions and disciplines and haspreviously been applied to endocrinology andhospital medicine.23,27-30 The classification in-cludes 10 high-level concepts integrated into aframework and supported by approximately 600concepts. This includes 4 primary types of safetyincident:

A reportable circumstance is a situation in which there

was significant potential for harm, but no incident

occurred;

A near miss is an event that could have resulted in un-

wanted consequences but did not because, either

by chance or through timely intervention, the

event did not reach the patient;

A no harm incident is one in which an event reached a

patient but no discernible harm resulted;

An adverse event is a harmful incident that results in

harm to a patient, resulting from a medical inter-

vention and not due to the underlying condition

of the patient.

The classification also includes 13 primary classesof incident type, defined as an event or circumstancethat could have resulted, or did result, in unneces-sary harm to a patient; and six primary classes ofcontributing factors/hazards, defined as the circum-stances, actions, or influences that are thought tohave played a part in the origin or developmentof an incident or to have increased the risk of a pa-tient safety incident.27

Two separate physician reviewers (A.D., L.M.)independently coded all incident reports anddebriefing responses. Each listed issue or eventdescribed in the reports was classified as acontributing factor or patient safety incident.Reviewers further classified patient safety inci-dents as reportable circumstance, near miss, no-harm event or adverse event, and applied codesto each reported issue using primary classes andsubdivisions from the WHO technical report.27,31

Disagreements were reconciled via consensus,and any issues for which consensus could notbe reached were resolved by a senior reviewer(D.L.).

Statistical analysis. Frequencies were calculatedfor primary class and subdivision of each incidentand contributing factor. Duplicate reports ofsafety issues and events within debriefings orincident reports were omitted from analysis. Thedata were summarized using descriptive statistics(frequencies and proportions). Interrater reli-ability was tested using Cohen’s kappa for eachprimary class based on the original pair of inde-pendent determinations by the two primaryreviewers (A.D. and L.M.). Data were analyzedusing SAS version 9.3 (SAS Institute Inc,Cary, NC).

RESULTS

Between April 1, 2010, and April 1, 2011, 467surgeries related to kidney transplant were per-formed (190 living donor nephrectomies, 190living donor kidney transplants, and 87 deceaseddonor kidney transplants). Of these, a conve-nience sample of 325 surgeries was selected forclinician debriefing. Characteristics of the pa-tient cohorts are shown in Table I. Patientsreferred to in both debriefing responses and inci-dent reports are representative of the overallcohort of kidney transplant donors and recipi-ents during the study period. A total of 270 de-briefing responses were collected, reporting 334patient safety issues: 179 patient safety incidents(range 0–7 per debriefing), 155 contributing fac-tors/hazards (0–5 per response), 49 mitigatingfactors (0–3 per response), and 5 ameliorating ac-tions (0–5 per response). During the same studyperiod, 57 incident reports were filed related tothe care of 46 kidney transplant patients, report-ing 92 patient safety issues: 56 incidents (0–1 perreport) and 36 contributing factors (0–2 perreport). Nursing staff and physician assistants(44/57; 77.2% and 7/57; 12.2%, respectively)completed the majority of incident reports,whereas nursing staff and attending physicianscompleted the majority of clinician debriefings(106/270; 40.3% and 84/270; 31.1%, respec-tively, Table II).

Web-based debriefing responses. Of this 334patient safety issues were reported via web-baseddebriefings, 179 were safety incidents (31 adverseevents, 19 no-harm incidents, 9 near misses, 120reportable circumstances) and 155 were contrib-uting factors (Fig 1, A). Reporting frequencyremained consistent throughout the study period.Incident and Contributing Factor classes arelisted in Table III, A. Among debriefings, the

Table I. Patient demographics

Debriefing Incident reportsAll kidney transplantation

recipients and donors P value

Age, mean ± SD 47.5 ± 13.7 49.5 ± 14.3 47.1 ± 13.7 NSMale sex 163 (50.2) 22 (47.8) 239 (51.2) NSRace/ethnicity

Non-Hispanic white 174 (53.5) 24 (52.2) 249 (53.3) NSNon-Hispanic black 78 (24.0) 12 (26.1) 107 (22.9) NSHispanic 53 (16.3) 6 (13.0) 83 (17.8) NSAsian 13 (4.0) 2 (4.4) 17 (3.6) NSOther 7 (2.2) — 11 (2.3) NS

LanguageEnglish 297 (91.4) 42 (91.3) 434 (92.9) NSSpanish 13 (4.0) 2 (4.3) 31 (6.6) NSOther 15 (4.6) 2 (4.3) 2 (0.4) <.05*,y

InsuranceMedicare 80 (24.6) 16 (34.8) 147 (31.4) <.05*Private 11 (3.4) 3 (6.5) 111 (23.7) <.05*,yUnknown/other 234 (72.0) 27 (58.7) 209 (44.7) <.05*,y,z

Primary diagnosisDonor 151 (46.5) 19 (41.3) 190 (40.6) NSESRD 143 (44.0) 21 (45.7) 190 (40.6) NSHypertensive chronic kidney 28 (8.6) 6 (13.0) 83 (2.7) <.05*,yMembranous nephritis NOS 1 (0.3) — 4 (0.8) —Renal failure 1 (0.3) — — —N/A 1 (0.3) — — —

Total number 325 46 467

*P-value 2 compares debriefing and all.yP-value 3 compares NETS and all.zP-value 1 compares debriefing and NETS.ESRD, End-stage kidney disease; N/A, not applicable; NETS, Northwestern Events Tracking System; NOS, not otherwise specified; NS, not significant; SD,standard deviation.

Table II. Debriefing versus incident reportrespondents

RespondentDebriefings,n (%)

Incidentreports, n (%)

Anesthesia attending 22 (8.4) 2 (3.5)Surgical attending 62 (23.6)Anesthesia fellow/resident 11 (4.2) 0Surgical fellow 17 (6.5) 0CRNA 14 (5.3) 44 (77.2)Circulating nurse 45 (17.1)Scrub nurse 47 (17.9)Observer 8 (3.0) N/APhysician assistant 31 (11.8) 7 (12.2)*Other 13 (4.9) 2 (3.5)Pharmacist N/A 1 (1.8)Director/manager N/A 1 (1.8)Total 270 57

*May include nurse practitioner; incident reports do not differentiatebetween different physician specialty and between different nursing staff.CRNA, Certified Registered Nurse Anesthetist; N/A, not available.

SurgeryVolume 156, Number 5

McElroy et al 1109

most common incident class reported was Re-sources/Organizational Management (49/179;27.4%), of which Human Resources/Staff

Availability/Adequacy was the most common sub-category (26/49; 53.1%). The second most com-mon incident class reported was MedicalDevice/Equipment (39/179; 21.8%), of whichFailure/Malfunction was the most common sub-type (19/39; 48.7%). The most common Contrib-uting Factor/Hazard type reported via debriefingwas Staff Factors (113/155; 72.9%), of whichCommunication Factors was the most commonsubtype (82/113; 72.6%).

Institutional incident reports. Of the 92 patientsafety issues reported via Incident Reports, 56 weresafety incidents (12 adverse events, 17 no-harmincidents, 9 near misses, 14 reportable circum-stances) and 36 were contributing factors (Fig 1,B). Incident and Contributing Factor classes arelisted in Table III, B. Among incident reports, themost common incident class reported was MedicalDevice/Equipment (16/56; 28.6%), of which Fail-ure/Malfunction was the most common subtype(9/16; 56.3%). The second most common inci-dent class reported was Patient Accidents (13/56;23.2%), of which Falls was the most common

Fig 1. Patient safety incidents reported. Categories ofpatient safety incidents include: adverse events, noharm incident, near miss and reportable circumstances,Pie chart demonstrates the distribution of categories forweb-based debriefing (A), and incidents reports (B).

SurgeryNovember 2014

1110 McElroy et al

subtype (3/13; 23.1%). The most commonContributing Factor/Hazard type reported via inci-dent report was Staff Factors (26/36; 72.2%), ofwhich Performance Factors was the most commonsubtype (15/26; 57.7%).

Most common safety vulnerabilities. The mostcommonly reported safety vulnerabilities in ourstudy were related to the surgical procedure(n = 29), the availability of human resources(n = 26), and medical device failure or malfunction(n = 19). Examples include, ‘‘Patient had difficultand unusual anatomy including the renal arteryand vein,’’ ‘‘Endovascular stapler malfunction; sta-pler worked initially when the renal artery was

stapled but did not fire for the renal vein after re-loading the stapler,’’ and ‘‘fellow not availablewhen paged to help bench the kidney in donoroperation.’’

Interrater reliability. As shown in Table III, goodinterrater reliability was found for both debriefingsurveys and incident reports (Cohen’s kappa0.659–1.000). The lowest agreement for incidentreport types occurred with the Clinical Administra-tion class due to interchange of the subclasses‘‘transfer of care’’ and ‘‘handover.’’ Four interraterreliabilities could not be calculated because noneof the categories were chosen on initial review byeither reviewer.

DISCUSSION

This study demonstrates that the proactive de-briefing of clinicians provides detailed and timelyinformation about patient safety risks occurringduring surgical care. The clinician debriefingcaptured significantly more patient safety issuesper patient and per response, compared with theincident reporting system, despite the fact that thedebriefing exclusively solicited patient safety issuesabout intraoperative delivery of care, whereas thehospital-wide incident reporting system solicitedreports about delivery of care throughout thepatient’s hospitalization. Interestingly, more than60% of all the filed incident reports reported onincidents in the ‘‘operating room’’ and ‘‘recoveryroom.’’

The type of patient safety issue reported wasquite different between the two reporting modal-ities. Debriefing responses provided more infor-mation pertaining to resources/organizationalmanagement and clinical processes/procedures,such as, ‘‘the operating room set up was differentfrom the room which we usually used for laparo-scopic donor nephrectomy.’’ Incident reportsprimarily reported patient accidents anddocumentation-related issues, such as ‘‘Improvedocumentation regarding anatomical variation inthe donor.the information I needed to take careof the patient only existed in OTTR, not in thehospital record. The patient’s med profile was notcompleted by transplant service or nurses on thefloor’’ (Fig 2). In addition, debriefing responses re-ported significantly more contributing factors thanincident reports (196/270; 72.6% vs 37/92;40.2%).

Our findings reinforce those of previous studiesin other settings, which have demonstrated theeffectiveness of clinician debriefings in collecting

Table III. Patient safety issue types from debriefings and incident reports

A. Debriefings n = 334 B. Incident reports n = 92

Incident types (Cohen’s kappa) n (%) Incident types (Cohen’s kappa) n (%)

Clinical Administration (0.919) 13 (7.3) Clinical Administration (0.659) 6 (10.7)Admission 6 Admission 2Consent 4 Handover 4Handover 3

Clinical Process/Procedure (0.818) 36 (20.1) Clinical Process/Procedure (0.733) 4 (7.1)Diagnosis/Assessment 4 Diagnosis/Assessment 1Procedure/Treatment/Intervention 29 Procedure/Treatment/Intervention 3Tests/Investigations 1Specimens/Results 2

Documentation (0.829) 16 (8.9) Documentation (0.847) 10 (17.9)Charts/Medical Records/Assessments/Consultations

12 Check ListsLabels/Stickers/Identification Bands/Cards

44

Forms 4 Instructions/Information/Policies/Procedures/Guidelines

2

Medication/IV Fluids (0.971) 17 (9.5) Medication/IV Fluids (0.855) 6 (10.7)Delivery 7 Administration/Delivery 4Preparation/Dispensing 5 Preparation/Dispensing 1Administration 3 Prescribing 1Prescribing 2 Supply/Ordering 1

Oxygen/Gas/Vapour (1.00) 1 (0.6)Delivery 1

Medical Device/Equipment (0.974) 39 (21.8) Medical Device/Equipment (1.00) 16 (28.6)Failure/Malfunction 19 Failure/Malfunction 9Lack of Availability 6 User Error 3Poor Presentation/Packaging 5 Poor Presentation/Packaging 2Inappropriate for Task 4 Lack of Availability 1Unclean/Unsterile 3 Unclean/Unsterile 1Dislodgement/Misconnection 1User Error 1

Behavior (0.951)Staff Behavior 4 (2.2)Noncompliant/Uncooperative/Obstructive 2Risky/Reckless/Dangerous 2

Patient Accidents (1.00) 4 (2.2) Patient Accidents (0.848) 13 (23.2)Piercing/Penetrating 2 Fall 3Threat to Breathing 1 Piercing/Penetrating 2Other 1 Blunt 1

Other 5Resources/Organizational Management (0.931) 49 (27.4) Resources/Organizational Management (1.00) 1 (1.8)

Human Resources/Staff Availability/Adequacy

26 Human Resources/Staff Availability/Adequacy

1

Organization of Teams/People 10Matching of Workload Management 9Protocols/Policies/Procedure/Guideline 3Availability/Adequacy 1

Total incidents 179 Total incidents 56

Contributing factors Contributing factors

Staff Factors (0.941) 113 (72.9) Staff Factors (n/a) 26 (72.2)Communication Factors 82 Communication Factors 9Cognitive Factors 15 Cognitive Factors 1Behavior 10 Performance Factors 15Performance Factors 6

(continued)

SurgeryVolume 156, Number 5

McElroy et al 1111

Table III. (continued)

Contributing factors Contributing factors

Patient Factors (1.00) 8 (5.2) Patient Factors (n/a) 3 (8.3)Patho-Physiologic/Disease Related Factors 8 Patho-Physiologic/Disease Related Factors 2

Communication Factors 1Organizational/Service Factors (n/a) 34 (21.9) Organizational/Service Factors (n/a) 7 (19.4)

Organizational Decisions/Culture 15 Protocols/Policies/Procedures/Processes 6Organization of Teams 9 Organization of Teams 1Resources/Workload 7Protocols/Policies/Procedures/Processes 3

Total contributing factors 155 Total contributing factors 36

Fig 2. Safety incident and contributing factor categories reported. The relative percent of safety incident reported indebriefings (dark line) vs incident reports (light line).

SurgeryNovember 2014

1112 McElroy et al

detailed information about medical errors andadverse events in healthcare.30,32-34 The type of pa-tient safety issues reported in both debriefings andincident reports support the position that patientsafety is improved by improving patient care deliv-ery systems rather than targeting individuals andtheir mistakes.35 The reported contributing factorsreinforce the notion that a single patient safetyincident often occurs subsequent to multiplecontributing factors.36

Another significant difference between the tworeporting systems was the degree of participation.

To improve patient safety, obtaining diverse per-spectives increases the likelihood to identifyvulnerabilities in the delivery of care. Physicianswere a significant contributor, supplying morethan 40% of debriefing responses, contrary tocontributing only 3.5% of incident reports.Although similar studies have reported difficultyin enrolling physicians, including surgeons, thisstudy demonstrates that physicians were willingparticipate in proactive reporting systems.37,38

The fact that the web-based debriefing success-fully solicited reports from nursing staff,

SurgeryVolume 156, Number 5

McElroy et al 1113

physician extenders (eg, physician assistants),technicians, physicians (eg, anesthesiologists, sur-geons), residents, and students is suggestive thatthis active, web-based tool is successfully inte-grated into the workflow and fewer barriers forparticipation exist than the traditional incidentreporting system.

Reporting of safety events by clinicians iscritical to moving health care towards greatertransparency. Barriers to widespread transparencyinclude perfectionism, the culture of shame andblame, fear of retribution, and lack of both formaland informal support for dealing with errors.Incident-reporting systems provide significant in-formation regarding institutional safety vulnera-bilities, such as equipment failure and patientaccidents. The addition of a web-based, proactiveclinician debriefing provided in close proximityto the conclusion of surgery allowed for increasedinformation about the coordination of care, suchas staffing adequacy and effectiveness of clinicalcare tools.

In contrast with previous studies that havereported a decrease in response rates after initialimplementation of a new safety reporting tool,reporting frequency has remained consistentbeyond the study period. This result is likelyattributable to the proactive nature of the tooland the continued distribution to all cliniciansinvolved in transplant care at the conclusion of thesurgical procedure. Similar to incident reportingsystems, web-based debriefings can enhance thepatient safety culture at an institution. Thefocused scope in which debriefings can beexecuted allows for more in-depth analysis andan ability to quickly provide staff feedback andpropose remediation. In addition, use of theWHO ICPS for classification allows for comparisonof issues across specialties and health systems andhospitals.

This study has several limitations that war-rant further discussion. First, the data providedare from a single center and although many ofour findings are supported by other studies,multicenter studies will be required to assessthe generalizability. Also, the ICPS is a broadclassification of patient safety issues and wasnot specifically designed to categorize surgicalcare.

In summary, a proactive web-based cliniciandebriefing was successfully implemented to learnabout patient safety issues in kidney transplanta-tion. The data from the debriefing significantly

increased the quantity and quality of informationabout patient safety issues. The debriefingoffered, multiple perspectives of a single safetyrisk, and offered more information about contrib-uting and mitigating factors, thereby providingimportant information for improvement. Thereports suggest that improvements focusing onimproving patient safety in kidney transplantationneed to focus on reducing intraoperative distrac-tions, improving clinician-clinician communica-tion and increasing the reliability of medicaldevices.

The integration of the web-based debriefinginto the workflow and into the electronic hos-pital records together with the incident report-ing system may be of great value for thehospital, but specifically for specialties, such astransplantation, where patient safety is para-mount, especially in the delivery of care todonors, where there is no margin for error.Finally, the goal of patient safety assessment is totranslate the information collected into action.39

We believe that the use of a structured classifica-tion system will allow for faster ability to inter-vene, but the ultimate success of our systemwill be demonstrated by an improvement in pa-tient outcomes.

The authors thank A. Brown, K. Hoke, and themembers of the Northwestern University TransplantOutcomes Research Collaborative (NUTORC) for theiropinions and suggestions for this work.

SUPPLEMENTARY DATA

Supplementary data associated with this article can befound in the online version at http://dx.doi.org/10.1016/j.surg.2014.05.013.

REFERENCES

1. AHRQ’s Patient Safety Initiative: Building Foundations,Reducing Risk. Rockville, MD: Agency for HealthcareResearch and Quality; December 2003 [May 30, 2013].Available from: http://www.ahrq.gov/research/findings/final-reports/pscongrpt/psiniapp1.html.

2. Aranaz-Andres JM, Limon R, Mira JJ, Aibar C, Gea MT, AgraY, et al. What makes hospitalized patients more vulnerableand increases their risk of experiencing an adverse event?Int J Qual Health Care 2011;23:705-12.

3. Friedman AL, Lee KC, Lee GD. Errors in ABO labeling ofdeceased donor kidneys: case reports and approach toensuring patient safety. Am J Transplant 2007;7:480-3.

4. Dobson R. College begins inquiry into removal of wrongkidney. BMJ 2000;320:332.

5. Dyer O. Doctors suspended for removing wrong kidney.BMJ 2004;328:246.

SurgeryNovember 2014

1114 McElroy et al

6. Vora NM, Basavaraju SV, Feldman KA, Paddock CD, OrciariL, Gitterman S, et al. Raccoon rabies virus variant transmis-sion through solid organ transplantation. JAMA 2013;310:398-407.

7. HIV transmitted from a living organ donor–New YorkCity, 2009. MMWR Morb Mortal Wkly Rep 2011;60:297-301.

8. Department of Health and Human Services Office of theInspector General. Adverse events in hospitals: Care studyof incidence among Medicare beneficiaries in two selectedcounties. Washington, DC: Department of Health and Hu-man Services; 2008.

9. Atkinson TM, Li Y, Coffey CW, Sit L, Shaw M, Lavene D,et al. Reliability of adverse symptom event reporting by cli-nicians. Qual Life Res 2012;21:1159-64.

10. Abecassis MM, Fisher RA, Olthoff KM, Freise CE, RodrigoDR, Samstein B, et al. Complications of living donor hepaticlobectomy–a comprehensive report. Am J Transplant 2012;12:1208-17.

11. Guimaraes-Souza NK, Dalboni MA, Camara NC, Medina-Pestana JO, Paheco-Silva A, Cendoroglo M. Infectious com-plications after deceased kidney donor transplantation.Transplant Proc 2010;42:1137-41.

12. Kohn LT, Corrigan Janet M, Donaldson Molla S, editors.To Err is Human: Building a Safer Health System. Com-mittee on Quality of Health Care in America, Institute ofMedicine. Washington, DC: National Academy Press;2000.

13. The Joint Commission. The Joint Commission’s SentinelEvent Policy: ten years of improving the quality and safetyof healthcare. Jt Comm Perspect 2005;25:1-5.

14. Holzmueller CG, Pronovost PJ, Dickman F, Thompson DA,Wu AW, Lubomski LH, et al. Creating the Web-based inten-sive care unit safety reporting system. J Am Med Inform As-soc 2005;12:130-9.

15. Battles JB, Stevens DP. Adverse event reporting systems andsafer healthcare. Qual Saf Health Care 2009;18:2.

16. Farley DO, Haviland A, Champagne S, Jain AK, Battles JB,Munier WB, et al. Adverse-event-reporting practices by UShospitals: results of a national survey. Qual Saf HealthCare 2008;17:416-23.

17. Guthrie P. US creates blame-free adverse event reporting.CMAJ 2006;174:19-20.

18. Pecoraro F, Luzi D. Serious adverse event reporting in amedical device information system. Stud Health TechnolInform 2011;169:834-8.

19. Heard GC, Sanderson PM, Thomas RD. Barriers to adverseevent and error reporting in anesthesia. Anesth Analg 2012;114:604-14.

20. Lingard L, Regehr G, Espin S, Whyte S. A theory-based in-strument to evaluate team communication in the operatingroom: balancing measurement authenticity and reliability.Qual Saf Health Care 2006;15:422-6.

21. van Beuzekom M, Akerboom SP, Boer F. Assessing systemfailures in operating rooms and intensive care units. QualSaf Health Care 2007;16:45-50.

22. Chrysant SG. Proactive compared with passive adverse eventrecognition: calcium channel blocker-associated edema.J Clin Hypertens (Greenwich) 2008;10:716-22.

23. Runciman W, Hibbert P, Thomson R, Van Der Schaaf T,Sherman H, Lewalle P. Towards an International Classifica-tion for Patient Safety: key concepts and terms. Int J QualHealth Care 2009;21:18-26.

24. Ladner DP, Ross O, Skaro A, Woods D, Lakhoo K, TorricelliA, et al, editors. Issues in Living Donor Kidney Transplant(LDKT) Identified by the NUTORC Proactive TransplantSafety Debriefing Tool. Philadelphia, PA: American Trans-plant Congress; 2011.

25. Ross O, Skaro AI, Woods D, Lakhoo K, Torricelli A, Lyuksem-burg V, et al, editors. Safety Issues in Living Donor KidneyTransplant Identified Through a Proactive Web-basedTransplantSafetyDebriefingTool.Washington,DC:AmericanPublic Health Association Annual Meeting; 2011.

26. Woods D, Skaro AI, Ladner DP, Ross O, Thurk J, TorricelliA, et al, editors. Proactive Safety Debriefings of Clinicians toAssess Patient Safety in Living Donor Liver Transplantation.Orlando, FL: National Patient Safety Foundation PatientSafety Congress; 2010.

27. Sherman H, Castro G, Fletcher M, Hatlie M, Hibbert P,Jakob R, et al. Towards an International Classificationfor Patient Safety: the conceptual framework. Int J QualHealth Care 2009;21:2-8.

28. Stewart MJ, Georgiou A, Hordern A, Dimigen M, WestbrookJI. What do radiology incident reports reveal aboutin-hospital communication processes and the use of healthinformation technology? Stud Health Technol Inform 2012;178:213-8.

29. Mikkelsen KL, Thommesen J, Andersen HB. Validating theDanish adaptation of the World Health Organization’s In-ternational Classification for Patient Safety classification ofpatient safety incident types. Int J Qual Health Care 2013;25:132-40.

30. de Feijter JM, de Grave WS, Muijtjens AM, Scherpbier AJ,Koopmans RP. A comprehensive overview of medical errorin hospitals using incident-reporting systems, patient com-plaints and chart review of inpatient deaths. PLoS One2012;7:e31125.

31. DuBay DA, Lynch R, Cohn J, Ads Y, Punch JD, PelletierSJ, et al. Is routine ureteral stenting cost-effective inrenal transplantation? J Urol 2007;178:2509-13; discus-sion 13.

32. Howe CL. A review of the Office of Inspector General’s re-ports on adverse event identification and reporting.J Healthc Risk Manag 2011;30:48-54.

33. Cooper JB, Blum RH, Carroll JS, Dershwitz M, FeinsteinDM, Gaba DM, et al. Differences in safety climate amonghospital anesthesia departments and the effect of a realisticsimulation-based training program. Anesth Analg 2008;106:574-84; table of contents.

34. Papaspyros SC, Javangula KC, Adluri RK, O’Regan DJ.Briefing and debriefing in the cardiac operating room.Analysis of impact on theatre team attitude and patientsafety. Interact Cardiovasc Thorac Surg 2010;10:43-7.

35. Hoffmann B, Beyer M, Rohe J, Gensichen J, Gerlach FM.‘‘Every error counts’’: a web-based incident reporting andlearning system for general practice. Qual Saf Health Care2008;17:307-12.

36. Pronovost PJ, Thompson DA, Holzmueller CG, LubomskiLH, Dorman T, Dickman F, et al. Toward learning frompatient safety reporting systems. J Crit Care 2006;21:305-15.

37. Milch CE, Salem DN, Pauker SG, Lundquist TG, KumarS, Chen J. Voluntary electronic reporting of medical er-rors and adverse events. An analysis of 92,547 reportsfrom 26 acute care hospitals. J Gen Intern Med 2006;21:165-70.

SurgeryVolume 156, Number 5

McElroy et al 1115

38. Levtzion-Korach O, Alcalai H, Orav EJ, Graydon-Baker E,Keohane C, Bates DW, et al. Evaluation of the contributionsof an electronic web-based reporting system: enabling ac-tion. J Patient Saf 2009;5:9-15.

39. Flink E, Chevalier CL, Ruperto A, Dameron P, Heigel FJ,Leslie R, et al. Lessons learned from the evolution of

mandatory adverse event reporting systems. In: HenriksenK, Battles JB, Marks ES, Lewin DI, editors. Advances in pa-tient safety: from research to implementation (Volume 3:Implementation Issues). Advances in Patient Safety. Rock-ville, MD: Agency for Healthcare Research and Quality;2005.