Automation in Surgical Adverse Event Documentation: Improving Completeness and Accuracy.

Abstract

Manual recording of surgical adverse events (AEs) is often incomplete and inconsistent. Automated systems linking structured notes to surgical secondary events (SSE) databases may improve accuracy and efficiency. We retrospectively compared surgeries from October 2021 to April 2022 (manual reporting) and January to July 2023 (automated reporting). In the automated cohort, AEs were captured via a structured note-linked SSE database. Outcomes included completeness-the proportion of AEs in notes also recorded in the SSE database-and accuracy, defined by concordance for procedure, complication type/grade, and management. Baseline demographics were similar between cohorts. Completeness improved from 20% to 94% ( P < 0.001). Minor AE capture increased from 7% to 96% ( P < 0.001), and major AE capture from 29% to 92% ( P < 0.001). Automated SSE reporting substantially improved the completeness and accuracy of surgical AE documentation, particularly for minor events, supporting more reliable surgical quality data collection.