Abstract

WAIN, H; CLARKE, DL  and  WALL, S. The rate of iatrogenic injuries in surgical patients appears resistant to multiple interventions: what can we learn from aviation safety?. S. Afr. j. surg. [online]. 2024, vol.62, n.1, pp.54-58. ISSN 2078-5151.  http://dx.doi.org/10.36303/SAJS.00197.

BACKGROUND: This project analyses all iatrogenic injuries from our department over the last decade and tracks their rate against several interventions METHODS: All patients who sustained an iatrogenic injury between 2012 and 2022 were reviewed RESULTS: A total of 946 iatrogenic injuries occurred in 731 patients. Sixty per cent of these patients were male; the median age was 39 years. Of 946 injuries, 574 (60.7%) occurred during an operation, and 372 (39.3%) were not related to an operation. Of the operative injuries 412 (71.8%) were enteric injuries. Of the 372 non-operative iatrogenic injuries 304 (82%) were due to indwelling devices (ID), and 34 (10%) occurred during flexible endoscopy. Fifty-five per cent of the injuries due to ID were due to central venous catheters (CVC) and urinary catheters (UC). CVC contributed toward 31% of all non-operation related iatrogenic injuries. One in 54 admissions (946/51 178) and one in 47 (574 /27 342) patients undergoing an operation sustained an iatrogenic injury. The annual rate of iatrogenic injuries did not decrease over the decade despite a multifaceted approach to reduce them. Interventions included electronic database development, procedural standardisation, and checklist implementation CONCLUSION: Despite multiple interventions over a decade, our rate of iatrogenic injury remains constant. Ongoing multifaceted efforts to reduce this rate must focus on engendering a culture of safety at all levels of healthcare if we hope to match the enviable safety record of the aeronautics industry

Keywords : iatrogenic injury; patient safety; safety.

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