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Objective: Determine how frequently intraoperative complications (IOC) are reported in the operative report and discharge summary.
Design: Retrospective cohort study of a prospectively maintained database.
Setting: Tertiary care academic medical center
Patients: Pts undergoing operation on a GI surgical service.
Intervention: Prospective complication recording via the Surgical Activity Tracking System(SATS)
Main Outcome Measure: Intraoperative complications as recorded in the op note, discharge summary and SATS.
Results: 8,896 pts had surgery during the study period. 152 had an IOC (1.7%). The op report failed to note 20 complications (13%) and discharge summaries neglected 22 (14%). 8 were concurrently missed by both. SATS failed to identify six IOC (4%). Nonintestinal lacerations were the most frequent complication not reported in the op note; only 25% of intraop arrhythmias were recorded. Anastomotic complications, respiratory complications and inadvertent enterotomies were almost always included in the op note.
Conclusions: A significant number of intraoperative complications, especially arrhythmias and nonintestinal lacerations, do not appear in the operative note or discharge summary. This has significant implications for quality assessment and improvement. Prospective data tracking has important advantages in this regard.