Analysis of "never events" following adult cardiac surgical procedures in the United States.

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The Journal of cardiovascular surgery.

MeSH Headings

Accidental Falls, Aged, Aorta, Thoracic, Cardiac Surgical Procedures, Catheter-Related Infections, Coronary Artery Bypass, Databases, Factual, Female, Glucose Metabolism Disorders, Health Resources, Heart Valve Prosthesis Implantation, Hospital Charges, Hospital Mortality, Humans, Length of Stay, Logistic Models, Male, Medical Errors, Middle Aged, Multivariate Analysis, Odds Ratio, Quality Indicators, Health Care, Retrospective Studies, Risk Factors, Time Factors, Treatment Outcome, United States, Urinary Tract Infections, Vascular Surgical Procedures


BACKGROUND: This study was conducted to determine the risk factors, nature, and outcomes of "never events" following open adult cardiac surgical procedures. Understanding of these events can reduce their occurrence, and thereby improve patient care, quality metrics, and cost reduction.

METHODS: "Never events" for patients included in the Nationwide Inpatient Sample who underwent coronary artery bypass graft, heart valve repair/replacement, or thoracic aneurysm repair between 2003-2011 were documented. These events included air embolism, catheter-based urinary tract infection (UTI), pressure ulcer, falls/trauma, blood incompatibility, vascular catheter infection, poor glucose control, foreign object retention, wrong site surgery and mediastinitis. Analysis included characterization of preoperative demographics, comorbidities and outcomes for patients sustaining never events, and multivariate analysis of predictive risk factors and outcomes.

RESULTS: A total of 588,417 patients meeting inclusion criteria were identified. Of these, never events occurred in 4377 cases. The majority of events were in-hospital falls, vascular catheter infections, and complications of poor glucose control. Rates of falls, catheter based UTIs, and glucose control complications increased between 2009-2011 as compared to 2003-2008. Analysis revealed increased hospital length of stay, hospital charges, and mortality in patients who suffered a never event as compared to those that did not.

CONCLUSIONS: This study establishes a baseline never event rate after cardiac surgery. Adverse patient outcomes and increased resource utilization resulting from never events emphasizes the need for quality improvement surrounding them. A better understanding of individual patient characteristics for those at risk can help in developing protocols to decrease occurrence rates.



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