Disclosure and reporting of surgical complications: a double-edged sword?
Approach to Improving Safety
Setting of Care
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.