The Western Australian Audit of Surgical Mortality: advancing surgical accountability

Objective: To describe the peer review process of the Western Australian Audit of Surgical Mortality (WAASM), selected outcomes and recommendations. Study design: Prospective audit using peer review of all cases of patients who died while under the care of a Western Australian surgeon between 1 January 2002 and 30 June 2004. Audit reviews were current to 30 September 2004. Participants and setting: 194 of 202 surgeons participated after a patient died under their care. Main outcome measures: Surgeon participation, deficiencies of care, deep vein thrombosis (DVT) prophylaxis, futile surgery, postmortem reviews, proportion of operations performed by consultant surgeons. Results: The audit process was complete for 896 of 1647 reported deaths (54%), while a further 503 (31%) were still under review at 30 September 2004. Twenty deaths associated with terminal care were excluded from analysis. Median patient age was 80 years, and 799 of the 876 patients who died (91%) had significant comorbidities that increased the risk of death. Deficiencies of care were reported in 179/876 (20%). In 45/876 deaths (5%) the deficiency of care was assessed to have caused the death, and 15 deaths were considered preventable. The risk of a deficiency of care was 1.9 times higher in elective admissions than emergency admissions. Autopsy was undertaken in 83/768 (11%) deaths with complete data. Changes in practice were noted in some areas targeted by WAASM, such as improved DVT prophylaxis. A problem with fluid management was recorded. Conclusion: Most patients who died were elderly, had complex comorbidities and were treated appropriately. The WAASM has helped to change surgical practice and emphasises the importance of ongoing systematic audit. The participation of surgeons demonstrates their commitment to accountability and supports the intention of the Royal Australasian College of Surgeons to extend the process throughout Australia and New Zealand.