ABSTRACT
A rapidly deployed ward-based screen and isolate initiative for Clostridium difficile carriers during an outbreak averted 5 of 10 expected hospital-acquired infections without identified harms. Each infection avoided required screening 197 and isolating 4.4 patients. Targeted C. difficile screening resulted in outbreak mitigation.
Subject(s)
Carrier State/diagnosis , Clostridium Infections/diagnosis , Cross Infection/diagnosis , Disease Outbreaks/prevention & control , Mass Screening , Aged , Boston , Carrier State/microbiology , Clostridioides difficile/isolation & purification , Clostridium Infections/prevention & control , Cross Infection/microbiology , Cross Infection/prevention & control , Feces/microbiology , Female , Hospitalization , Hospitals , Humans , Male , Prospective Studies , Risk FactorsABSTRACT
Our knowledge of the types of intraoperative patient safety events, their harm to patients, and relationship to postoperative complications is sparse. This study examined intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) voluntarily reported by providers using two programs at our hospital: surgical debriefing and incident reporting. Among the 3020 surgical procedures assessed, 142 iMEs and 103 iAEs were reported, yielding an overall rate of 8%. Of these events, 135 (55%) were obtained from incident reporting and 110 (45%) from surgical debriefing. The overall association between intraoperative events (iMEs and iAEs) and 30-day postoperative morbidity was significant (adjusted odds ratioâ¯=â¯1.08 with 95% confidence interval (CI) of (1.03, 1.13). This association was stronger when we included only the iAEs (1.47, 95% CI (1.35, 1.58)). Our findings suggest that hospitals should consider using both programs to obtain a more complete picture of intraoperative patient safety and to reduce postoperative morbidity.
