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PSNet: Patient Safety Network
Journal Article

Disclosure and reporting of surgical complications: a double-edged sword?

Stahel PF, Flierl MA, Smith WR, et al. American journal of medical quality : the official journal of the American College of Medical Quality. 2010;25:398-401.

An orthopedic surgery department implemented a confidential, real-time system for reporting intraoperative adverse events and analyzed these events in structured morbidity and mortality conferences. Although physicians felt this process improved patient care, it resulted in a significant increase in reported error rates, which, as the authors point out, could have resulted in lower quality ratings for the department.