Patient safety continues to be a national healthcare priority since recent landmark reports and population-based studies have estimated that 44,000 to 98,000 patients die every year in the United States as a result of medical errors. “As there has been increased interest in patient safety and benchmarking of healthcare quality over the past 20 years, it’s become critical to study the clinical and financial impact of intraoperative adverse events (AEs),” says Haytham Kaafarani, MD, MPH.

Few studies to date have provided evidence on specific aspects of intraoperative AEs. “Much of the research focuses on complications after surgeries are performed,” Dr. Kaafarani says. “On the other hand, intraoperative AEs have been a Pandora’s box because they are much more challenging to study.”


Taking a Closer Look

For a study published in Surgery, Dr. Kaafarani and colleagues investigated the additional healthcare charges attributable to the occurrence of intraoperative AEs. The analysis merged administrative data as well as clinical data from the American College of Surgeons’ National Surgical Quality Improvement Program databases for all patients undergoing abdominal surgery from January 2007 to October 2012.

The researchers used the ICD-9-CM-based Patient Safety Indicator “accidental puncture/laceration” to initially screen participants for potential intraoperative AEs. All flagged medical records were systematically reviewed to remove “false positives” or confirm the real occurrence of an intraoperative AE. The study group then performed multivariable analyses (controlling for demographics, comorbidities/laboratory values, procedure type, and approach and complexity of surgery) to assess the increase in healthcare charges that were independently associated with the occurrence of intraoperative AEs.


Important Results

Of 9,111 patients included in the study, 183 were confirmed to have intraoperative AEs. Patients in the intraoperative AE group had higher median total charges ($27,169 vs $13,312), direct charges ($17,808 vs $8,738) and indirect charges ($9,396 vs $4,568) when compared with patients without intraoperative AEs. In the multivariable analyses, “On average, intraoperative AEs independently predicted an increase in total hospitalization charges by about 40%,” says Dr. Kaafarani. “Intraoperative AEs can have a snowball effect on costs that extends beyond the operating room for patients undergoing abdominal surgery.”

In fact, the study broke down several types of charges in which intraoperative AEs were shown to increase costs independently and significantly:

  • Direct charges: 42%
  • Indirect charges: 39%
  • Operating room charges: 27%
  • Laboratory/radiology charges: 54%
  • Alimentation/medical therapy charges: 48%

In light of the findings, Dr. Kaafarani says increased efforts for primary and secondary prevention are critical to reducing the risk of intraoperative AEs. “Clinicians need to identify specific patient factors that increase risks for intraoperative AEs, such as re-do surgery,” he says. “These risk factors should be discussed prior to surgery and prevention plans should be developed in advance. It’s also important to prevent the downside effects of complications. Some patients may need to be monitored more closely than others, especially if they develop intraoperative AEs. Such efforts may lead to major cost savings along with improvements in patient safety and surgical quality.”


Haytham Kaafarani, MD, MPH, is an Assistant Professor of Surgery at Harvard Medical School; and the Director of Patient Safety and Quality in the Division of Trauma, Emergency Surgery, & Surgical Critical Care at Massachusetts General Hospital.

Haytham M.A. Kaafarani, MD, MPH, has indicated to Physician’s Weekly that he has no financial disclosures to report.