Surgical Neurology International OPEN ACCESS
SNI: Neurosurgical Developments on the Horizon, a supplement to SNI
For entire Editorial Board visit : http://www.surgicalneurologyint.com
Editor: Michel Kliot, MD UCSF Medical Center San Francisco, CA 94143
Medical errors in neurosurgery John D. Rolston, Corinna C. Zygourakis, Seunggu J. Han, Catherine Y. Lau1, Mitchel S. Berger, Andrew T. Parsa2 Department of Neurological Surgery, 1Division of Hospital Medicine, University of California at San Francisco, San Francisco, CA, 2Department of Neurological Surgery, Northwestern University, Chicago, IL, USA E‑mail: *John D. Rolston ‑ [email protected]; Corinna C. Zygourakis ‑ [email protected]; Seunggu J. Han ‑ [email protected]; Catherine Y. Lau ‑ [email protected]; Mitchel S. Berger ‑ [email protected]; Andrew T. Parsa ‑ [email protected] *Corresponding author
Received: 21 November 13 Accepted: 27 May 14 Published: 13 October 14 This article may be cited as: Rolston JD, Zygourakis CC, Han SJ, Lau CY, Berger MS, Parsa AT. Medical errors in neurosurgery. Surg Neurol Int 2014;5:S435-40. Available FREE in open access from: http://www.surgicalneurologyint.com/text.asp?2014/5/11/435/142777 Copyright: © 2014 Rolston JD. This is an open‑access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract Background: Medical errors cause nearly 100,000 deaths per year and cost billions of dollars annually. In order to rationally develop and institute programs to mitigate errors, the relative frequency and costs of different errors must be documented. This analysis will permit the judicious allocation of scarce healthcare resources to address the most costly errors as they are identified. Methods: Here, we provide a systematic review of the neurosurgical literature describing medical errors at the departmental level. Eligible articles were identified from the PubMed database, and restricted to reports of recognizable errors across neurosurgical practices. We limited this analysis to cross‑sectional studies of errors in order to better match systems‑level concerns, rather than reviewing the literature for individually selected errors like wrong‑sided or wrong‑level surgery. Results: Only a small number of articles met these criteria, highlighting the paucity of data on this topic. From these studies, errors were documented in anywhere from 12% to 88.7% of cases. These errors had many sources, of which only 23.7-27.8% were technical, related to the execution of the surgery itself, highlighting the importance of systems‑level approaches to protecting patients and reducing errors. Conclusions: Overall, the magnitude of medical errors in neurosurgery and the lack of focused research emphasize the need for prospective categorization of morbidity with judicious attribution. Ultimately, we must raise awareness of the impact of medical errors in neurosurgery, reduce the occurrence of medical errors, and mitigate their detrimental effects.
Access this article online Website: www.surgicalneurologyint.com DOI: 10.4103/2152-7806.142777 Quick Response Code:
Key Words: Adverse events, medical error, neurological surgery, quality improvement, systems‑based practice
INTRODUCTION Preventable medical errors lead to the death of up to 98,000 Americans annually and cost the U.S. economy
over $17 billion per year.[9,16] The most expensive of these errors are related to surgery, with postoperative infections, device failure, post‑laminectomy syndrome, and operative hemorrhage comprising four of the top five causes. These S435
SNI: Neurosurgical Developments on the Horizon 2014,Vol 5, Suppl 10 - A Supplement to SNI
four causes together account for over $6 billion annually, roughly one‑third of the total financial burden of medical error.[16] To what degree neurosurgical care contributes to these errors is unknown, as is the resultant mortality, morbidity, and financial impact. Mapping the neurosurgical landscape of medical errors will allow us to direct our limited resources to the most pressing problems. Focused interventions have the potential to improve patient outcomes and reduce unnecessary healthcare costs, both of which are becoming increasingly important with new legislative initiatives that target cost‑effective care.[1,7,8] While many surgical practices have already adopted error‑mitigating techniques, like the World Health Organization (WHO) Safe Surgery Checklist,[5,20] we still do not know what neurosurgery‑specific errors are most costly (in terms of morbidity, mortality, and financial burden) and which we have the potential to effectively mitigate. As a first attempt to chart the environment of medical errors in neurosurgery, we conducted a systematic literature review of published data regarding neurosurgical errors. We report these data, analyze the results, and propose additional studies that must be carried out to advance this critical issue in our field. Importantly, we stress that this review covers medical errors, and not complications or adverse events. Although there is disagreement, medical errors are defined as acts of “commission (doing something wrong) or omission (failing to do the right thing), leading to an undesirable outcome or significant potential for such an outcome.”[18] Adverse events, in contrast, are defined by actual harm. According to the Institute for Healthcare Improvement, an adverse event is an “[u]nintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment, or hospitalization, or that results in death”.[18] Far more literature covers adverse events in neurosurgery (e.g.,[6,12,21,22]), possibly because such events are more objectively measurable. Nonetheless, errors are incredibly important, and below we report the research to date on this subject.
METHODS A PubMed search was performed on the terms “medical error,” “surgical error,” “patient safety,” or “quality improvement” in conjunction with the terms “neurosurgery” or “neurological surgery.” Articles were reviewed by the authors and excluded if they limited their discussion to only a single surgical procedure, only a single error, or did not discuss identifiable medical errors. Additionally, articles describing adverse events that we could not identify as preventable or nonpreventable were excluded. The purpose of these limitations was to place focus on the systems level of errors. Only S436
English‑language articles describing human patients were included. The references within identified articles were also reviewed for relevant manuscripts. From each identified article, the type and frequency of errors were abstracted.
RESULTS A total of 127 manuscripts were identified with our search terms [Figure 1]. Of these, only two met our inclusion criteria.[2,15] Several papers were notable for covering adverse events in a thorough manner,[4,6,10,14,23] but did not include enough information to identify errors as separate from nonpreventable adverse events, and were therefore excluded. The two medical error articles meeting our inclusion criteria are discussed in detail below. Stone et al.[15] prospectively recorded errors by a single neurosurgeon as he operated on 1108 consecutive patients between 2000 and 2006 in Toronto, Canada. In this study, errors were defined as “any act of omission or commission resulting in a deviation from a perfect course for the patient”.[15] Complications were defined as “as morbidities or mortalities.” A total of 76.1% of the studied cases were cranial procedures, 22.7% spinal procedures (with 1.2% classified as “other”), and two‑thirds of the cases (67.7%) used general anesthesia. The authors reported errors in 965 out of 1108 patients (87.1%), with an average of 2.4 ± 1.76 errors per case. Errors were classified as technical (27.8%), contamination (25.3%), equipment failure/missing (18.2%), delay (12.5%), nursing (5.7%), anesthesia (4.4%), judgment (2.8%), and communication (1.9%; Table 2). Overall, there were more errors in cranial as compared to spinal cases (2.5 ± 1.8 errors per cranial case vs. 2.2 ± 1.7 errors per spinal case; P
SNI: Neurosurgical Developments on the Horizon, a supplement to SNI
For entire Editorial Board visit : http://www.surgicalneurologyint.com
Editor: Michel Kliot, MD UCSF Medical Center San Francisco, CA 94143
Medical errors in neurosurgery John D. Rolston, Corinna C. Zygourakis, Seunggu J. Han, Catherine Y. Lau1, Mitchel S. Berger, Andrew T. Parsa2 Department of Neurological Surgery, 1Division of Hospital Medicine, University of California at San Francisco, San Francisco, CA, 2Department of Neurological Surgery, Northwestern University, Chicago, IL, USA E‑mail: *John D. Rolston ‑ [email protected]; Corinna C. Zygourakis ‑ [email protected]; Seunggu J. Han ‑ [email protected]; Catherine Y. Lau ‑ [email protected]; Mitchel S. Berger ‑ [email protected]; Andrew T. Parsa ‑ [email protected] *Corresponding author
Received: 21 November 13 Accepted: 27 May 14 Published: 13 October 14 This article may be cited as: Rolston JD, Zygourakis CC, Han SJ, Lau CY, Berger MS, Parsa AT. Medical errors in neurosurgery. Surg Neurol Int 2014;5:S435-40. Available FREE in open access from: http://www.surgicalneurologyint.com/text.asp?2014/5/11/435/142777 Copyright: © 2014 Rolston JD. This is an open‑access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract Background: Medical errors cause nearly 100,000 deaths per year and cost billions of dollars annually. In order to rationally develop and institute programs to mitigate errors, the relative frequency and costs of different errors must be documented. This analysis will permit the judicious allocation of scarce healthcare resources to address the most costly errors as they are identified. Methods: Here, we provide a systematic review of the neurosurgical literature describing medical errors at the departmental level. Eligible articles were identified from the PubMed database, and restricted to reports of recognizable errors across neurosurgical practices. We limited this analysis to cross‑sectional studies of errors in order to better match systems‑level concerns, rather than reviewing the literature for individually selected errors like wrong‑sided or wrong‑level surgery. Results: Only a small number of articles met these criteria, highlighting the paucity of data on this topic. From these studies, errors were documented in anywhere from 12% to 88.7% of cases. These errors had many sources, of which only 23.7-27.8% were technical, related to the execution of the surgery itself, highlighting the importance of systems‑level approaches to protecting patients and reducing errors. Conclusions: Overall, the magnitude of medical errors in neurosurgery and the lack of focused research emphasize the need for prospective categorization of morbidity with judicious attribution. Ultimately, we must raise awareness of the impact of medical errors in neurosurgery, reduce the occurrence of medical errors, and mitigate their detrimental effects.
Access this article online Website: www.surgicalneurologyint.com DOI: 10.4103/2152-7806.142777 Quick Response Code:
Key Words: Adverse events, medical error, neurological surgery, quality improvement, systems‑based practice
INTRODUCTION Preventable medical errors lead to the death of up to 98,000 Americans annually and cost the U.S. economy
over $17 billion per year.[9,16] The most expensive of these errors are related to surgery, with postoperative infections, device failure, post‑laminectomy syndrome, and operative hemorrhage comprising four of the top five causes. These S435
SNI: Neurosurgical Developments on the Horizon 2014,Vol 5, Suppl 10 - A Supplement to SNI
four causes together account for over $6 billion annually, roughly one‑third of the total financial burden of medical error.[16] To what degree neurosurgical care contributes to these errors is unknown, as is the resultant mortality, morbidity, and financial impact. Mapping the neurosurgical landscape of medical errors will allow us to direct our limited resources to the most pressing problems. Focused interventions have the potential to improve patient outcomes and reduce unnecessary healthcare costs, both of which are becoming increasingly important with new legislative initiatives that target cost‑effective care.[1,7,8] While many surgical practices have already adopted error‑mitigating techniques, like the World Health Organization (WHO) Safe Surgery Checklist,[5,20] we still do not know what neurosurgery‑specific errors are most costly (in terms of morbidity, mortality, and financial burden) and which we have the potential to effectively mitigate. As a first attempt to chart the environment of medical errors in neurosurgery, we conducted a systematic literature review of published data regarding neurosurgical errors. We report these data, analyze the results, and propose additional studies that must be carried out to advance this critical issue in our field. Importantly, we stress that this review covers medical errors, and not complications or adverse events. Although there is disagreement, medical errors are defined as acts of “commission (doing something wrong) or omission (failing to do the right thing), leading to an undesirable outcome or significant potential for such an outcome.”[18] Adverse events, in contrast, are defined by actual harm. According to the Institute for Healthcare Improvement, an adverse event is an “[u]nintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment, or hospitalization, or that results in death”.[18] Far more literature covers adverse events in neurosurgery (e.g.,[6,12,21,22]), possibly because such events are more objectively measurable. Nonetheless, errors are incredibly important, and below we report the research to date on this subject.
METHODS A PubMed search was performed on the terms “medical error,” “surgical error,” “patient safety,” or “quality improvement” in conjunction with the terms “neurosurgery” or “neurological surgery.” Articles were reviewed by the authors and excluded if they limited their discussion to only a single surgical procedure, only a single error, or did not discuss identifiable medical errors. Additionally, articles describing adverse events that we could not identify as preventable or nonpreventable were excluded. The purpose of these limitations was to place focus on the systems level of errors. Only S436
English‑language articles describing human patients were included. The references within identified articles were also reviewed for relevant manuscripts. From each identified article, the type and frequency of errors were abstracted.
RESULTS A total of 127 manuscripts were identified with our search terms [Figure 1]. Of these, only two met our inclusion criteria.[2,15] Several papers were notable for covering adverse events in a thorough manner,[4,6,10,14,23] but did not include enough information to identify errors as separate from nonpreventable adverse events, and were therefore excluded. The two medical error articles meeting our inclusion criteria are discussed in detail below. Stone et al.[15] prospectively recorded errors by a single neurosurgeon as he operated on 1108 consecutive patients between 2000 and 2006 in Toronto, Canada. In this study, errors were defined as “any act of omission or commission resulting in a deviation from a perfect course for the patient”.[15] Complications were defined as “as morbidities or mortalities.” A total of 76.1% of the studied cases were cranial procedures, 22.7% spinal procedures (with 1.2% classified as “other”), and two‑thirds of the cases (67.7%) used general anesthesia. The authors reported errors in 965 out of 1108 patients (87.1%), with an average of 2.4 ± 1.76 errors per case. Errors were classified as technical (27.8%), contamination (25.3%), equipment failure/missing (18.2%), delay (12.5%), nursing (5.7%), anesthesia (4.4%), judgment (2.8%), and communication (1.9%; Table 2). Overall, there were more errors in cranial as compared to spinal cases (2.5 ± 1.8 errors per cranial case vs. 2.2 ± 1.7 errors per spinal case; P
