Prospective collection and analysis of error data in a neurosurgical clinic

Clinical Neurology and Neurosurgery
Jan BoströmJohannes Schramm

Abstract

It is still unknown how often surgical errors lead to clinical impact and contribute to complications for patients. Hence, reliable and detailed prospective collection and analysis of error data is considered essential and a valuable key to error prevention. In a mono center study, errors and complications were prospectively recorded concerning consecutive patients undergoing elective and emergency neurosurgical procedures. A broad error definition (deviation from an optimal course=DOC) was used to catch as much as possible errors. Each error was scored for type, severity, preventability, and consequence. More than 1100 consecutive operative cases were studied, 756 cases could be evaluated, among them 529 elective and 227 emergency cases. A total of 190 DOC (25%) were found. The most common DOC was primarily due to (a) equipment failure or missing equipment, then to (b) pre-operative mismanagement, and only to (c) non-optimal procedures. 26% DOC were classified as medical, 69% as non-medical, and 5% as combined. Of all deviations identified, 16% were considered relevant errors, with only 4% slightly impacting the clinical course of the patient. Hence, in less than 1% of all cases a clinically relevant medical error occurred. 19...Continue Reading

References

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Citations

Nov 3, 2012·Neurosurgical Focus·Ági OszvaldErdem Güresir
Jun 14, 2014·Journal of Neurosurgery·Adetunji A Oremakinde, Mark Bernstein
Jul 12, 2014·International Orthopaedics·Reiner WirbelMarius Dehne
Nov 6, 2014·Surgical Neurology International·John D RolstonAndrew T Parsa
Jul 28, 2013·BMJ Quality & Safety·Ruwan A WeerakkodyColin D Bicknell
Jun 16, 2015·Journal of Surgical Education·James A BalogunMark Bernstein
Mar 17, 2015·Neurosurgery Clinics of North America·John D Rolston, Mark Bernstein
Dec 22, 2020·The International Journal of Medical Robotics + Computer Assisted Surgery : MRCAS·Marc ZanelloJohan Pallud

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