Key result
Cause and effect analysis identified 390 system failures contributing to 130 surgical adverse events, revealing that 63% of contributing causes were undetected by current medical review processes.
Observational (n=130)
No
Current medical review processes fail to detect the majority of system failures contributing to surgical adverse events, highlighting the inadequacy of morbidity and mortality reviews alone for risk management.
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Current review processes may miss most system failures; leaves open whether enhanced detection improves surgical outcomes in prospective studies.
Morris et al. (2003) conducted an observational in Surgical adverse events (n=130). Cause and effect analysis vs. Current medical review process was evaluated on System failures contributing to adverse events. Cause and effect analysis identified 390 system failures contributing to 130 surgical adverse events, revealing that 63% of contributing causes were undetected by current medical review processes.
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