Failures in process in postoperative care are common and cause patient harm

Process failures in caring for patients after elective surgery are common and were found to cause harm about fifty percent of the time, according to a study in the Annals of Surgery.

For the study, the post-operative care of fifty patients who had major elective surgery was monitored by two surgeons.  Key findings include:

  • A total of 256 process failures were identified, of which 85% were preventable and 51% directly led to patient harm.
  • The most frequent process failures were medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. 
  • Communication problems and delays were the main cause of these failures.

The authors conclude that interventions are needed in order to prevent failures in process. 

(Sources: The Advisory Board Daily Briefing,, October 4, 2012; The Annals of Surgery,, October 2012)