Anne van Dalen

20 I General Introduction SURGICAL ADVERSE EVENTS IN THE OPERATING ROOM Definitions An adverse event is usually defined as “an unintended injury or complication resulting in harm that is caused by medical management error, the failure of a planned medical action to be completed, or any deviation from usual medical care that poses a risk of harm.” 1,2,9 Adverse events are usually not the result of individual failure, but the consequence of an uninterrupted chain of events and decisions, spanning multiple phases of surgical care. 67 Active failures are the unsafe acts committed by people who are in direct contact with the patient or the system. Latent conditions are inevitable within the system. They arise from decisions made by designers, builders, procedure writers, and top level management. Such decisions may be mistaken, but they need not be. 67 Professor dr. Charles Vincent, one of the world’s pioneers in patient safety, has identified the key patient safety terms Figure 3. The World Health Organization Surgical Safety Checklist