theatre and surgery
Severe adverse events
in the operating theatre
Unexpected patient harm occurs more frequently than expected in the operating theatre.
Learning to deal with these situations, as well as using available resources, might effectively prevent
future harm as well as improve the quality of the attention provided during serious adverse events
Carlos Rodrigo Molina
Mendoza
Silvia Ramírez Ordoñez
Department of
Anesthesia and
Critical Care, Hospital
Universitario Fundación
Alcorcón, Madrid, Spain
Not all adverse events are necessarily severe, and
thereby do not require an extensive institutional
response. Severe adverse events are unexpected
and undesirable situations that are related to
death or great physical and/or psychological
damage suffered by patients under medical
attention. These events always require not only
a strong institutional response, 1 but also one that
is immediate and helps to identify the underlying
causes that lead to them.
Appropriate response should start within
60 minutes of the event, following a structured
process that must be familiar to the professionals
involved and executed by a ‘director’ with
abilities such as leadership and team work. This
figure should be ultimately responsible to lead
the response, and should be a member of senior
hospital personnel (for example, Medical Director,
Chief of Staff, Head of Human Resources), and, at
the same time, someone who is able to delegate
tasks appropriately. There must be no room for
improvisation, as the quality and success of the
initial response will determine the capacity to
provide real solutions and better results.
CANDOR
A good example of a complete and well-developed
process to respond to a severe adverse event is
The Communication and Optimal Resolution
(CANDOR) process. 2 It was developed by the
Agency for Healthcare Research and Quality
(AHRQ) and is a unique tool to approach and
provide immediate response to severe adverse
events in the healthcare setting. This process
improves patient safety through an empathetic,
fair, and just approach to medical errors, and
promotes a culture of safety that focuses on:
caring for the patient, family, and caregiver; an
in-depth event investigation and analysis; and
resolution. Professionals trained in this type of
process or at least familiar with them should be
designated to coordinate specific tasks once the
severity of the event is determined. A proposed
approach based on the CANDOR process is shown
in Figure 1.
Once the event has been identified and
declared, the institutional response will be
directed simultaneously to attend the patient and
professionals involved, while investigation and
analysis is underway. The final goal in to provide
appropriate resolution for the event and the
different groups affected: patient and family,
caregivers, and hospital, as ‘first’, ‘second’ and
‘third’ victims.
Despite the variety of severe adverse events
that might arise in the operating theatre, two
main aspects determine a better approach and
hence, better solutions for the different parties
involved. On the one hand, a generic action plan
or process will provide specific directions to
follow and consequently reduce the times spent
to accomplish partial or total resolution. 3 On the
other hand, training professionals that might
have to deal with these unexpected situations at
different levels is also important, and also
possible through tools such as simulation
exercises.
Attending the victims
Once the adverse event has been declared, the
figure 1
Dealing with a severe adverse event: CANDOR
Identify a severe
adverse event
Communication
and attending to
the patient and
professionals
involved
Activate
institutional
response
Investigation and
analysis
5
HHE 2018 | hospitalhealthcare.com
Resolution
• Patient and
family
• Professionals
• Institution