gms | German Medical Science

59th Annual Meeting of the German Society of Neurosurgery (DGNC)
3rd Joint Meeting with the Italian Neurosurgical Society (SINch)

German Society of Neurosurgery (DGNC)

1 - 4 June 2008, Würzburg

Prospective collection and analysis of error data in a neurosurgical clinic

Prospektive Fragebogen-Studie zu Fehlern bei neurochirurgischen Eingriffen

Meeting Abstract

Search Medline for

  • corresponding author J. Boström - Neurochirurgische Klinik, Universitätsklinikum Bonn
  • A. Yacoub - Neurochirurgische Klinik, Universitätsklinikum Bonn
  • J. Schramm - Neurochirurgische Klinik, Universitätsklinikum Bonn

Deutsche Gesellschaft für Neurochirurgie. Società Italiana di Neurochirurgia. 59. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie e.V. (DGNC), 3. Joint Meeting mit der Italienischen Gesellschaft für Neurochirurgie (SINch). Würzburg, 01.-04.06.2008. Düsseldorf: German Medical Science GMS Publishing House; 2008. DocDI.08.05

The electronic version of this article is the complete one and can be found online at:

Published: May 30, 2008

© 2008 Boström et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.



Objective: Surgical errors are common, but often preventable. How often they lead to clinical impact and contribute to complications for patients is not definitively known. Hence detailed prospective collection and analysis of error data is essential and the key to prevention.

Methods: In a single center study, we prospectively recorded errors and complications for consecutive patients undergoing elective and emergency neurosurgical procedures. Each error was scored for type, severity, preventability and consequence.

Results: Between December 2006 and May 2007, 1121 consecutive operative cases were studied, 756 cases could be evaluated, consisting of 526 elective cases and 227 emergency cases (423 cranial, 241 spinal, 81 peripheral and 25 other procedures). A total of 190 errors (25%) were found. The most common errors were equipment failure or missing equipment, pre-operative management errors and only in third place procedural errors in the strict sense. Referring to all 190 errors, we have identified 49 medical errors (26%), 132 non-medical errors (69%), and 9 combined errors (5%). Of all errors, 16% were considered relevant, with only 4% of the errors slightly impacting the clinical course of the patient. Only 19% of all errors were deemed not preventable. No significant correlation with age or sex could be demonstrated. Unexpectedly, the error rate in emergency cases was lower than in elective cases (16% vs. 30%). A propensity for error was identified with technically complex cranial procedures and patients with higher American Society of Anesthesiologists scores. Without permanent supervision, the rate of error documentation is significantly lower.

Conclusions: We were able to identify typical recurring errors on the one hand, on the other hand some procedure and patient characteristics interrelating with surgical errors were found. Prospective error documentation and analysis is a valuable, but time consuming method, because a permanent close supervision seems to be mandatory to maintain quality of documentation. In general, one has to track and analyze errors to ensure that systems may be developed to prevent their occurrence.