Artikel
The incidence and nature of adverse events and their association with human error in neurosurgery – a prospective observational study
Die Häufigkeit und Art unerwünschter Ereignisse und der Zusammenhang mit menschlichem Versagen in der Neurochirurgie – eine prospektive Beobachtungsstudie
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Autoren
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Hanno S. Meyer
- Klinikum rechts der Isar, Technical University Munich, Department of Neurosurgery, München, Deutschland
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Arthur Wagner
- Klinikum rechts der Isar, Technical University Munich, Department of Neurosurgery, München, Deutschland
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Thomas Obermüller
- Klinikum rechts der Isar, Technical University Munich, Department of Neurosurgery, München, Deutschland
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Chiara Negwer
- Klinikum rechts der Isar, Technical University Munich, Department of Neurosurgery, München, Deutschland
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Maria Wostrack
- Klinikum rechts der Isar, Technical University Munich, Department of Neurosurgery, München, Deutschland
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Sandro Krieg
- Klinikum rechts der Isar, Technical University Munich, Department of Neurosurgery, München, Deutschland
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Jens Gempt
- Klinikum rechts der Isar, Technical University Munich, Department of Neurosurgery, München, Deutschland
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Bernhard Meyer
- Klinikum rechts der Isar, Technical University Munich, Department of Neurosurgery, München, Deutschland
| Veröffentlicht: | 4. Juni 2021 |
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Gliederung
Text
Objective: Adverse events (AEs) in neurosurgery are a relevant cause of disability or death. Their incidence is a key quality indicator that plays an important role in the future of health care. The goal of this study was to determine the overall incidence, nature and severity of AEs in neurosurgical care, and to investigate the contribution of human performance deficiencies.
Methods: This was a prospective observation of all in-house AEs at the neurosurgical department of an academic supra-maximum medical care center. A consecutive sample including all 4176 inpatients treated at this institution was obtained between September 2019 and September 2020. AEs were recorded daily. The type of AE according to the American College of Surgeons, the AE severity according to the SAVES-v2 classification and a potential contribution of human error was evaluated weekly by consensus of all senior neurosurgeons of the department. Human errors were classified into one of five categories [1]: planning, execution, rules violation, communication, or teamwork.
Results: The case mix index of all patients was 3.16. There were 1611 AEs. 1043 (25.0% of all) patients had at least one AE. The most frequent types of AE were urinary and neurological events, followed by unplanned returns to the OR and iatrogenic surgical injuries (Table 1 [Tab. 1]). In 25.9% of these cases, the major AE was associated with human error, mostly with execution (18.3%) or planning (5.6%) deficiencies (Table 2 [Tab. 2]). 48.8% of all cases with AEs were severe (SAVES grade 3 or higher). In the subgroup of patients with AEs related to human error, there were more severe AEs than in the subgroup with spontaneous AEs (69.6% vs. 41.5% with SAVES grade 3 or higher). 361 patients (8.6%) had multiple AEs. This subgroup also had more severe AEs (67.6% SAVES grade 3 or higher). There were more severe AEs in cranial neurosurgery than in spinal neurosurgery (57.6 vs. 39.4%).
Conclusion: Prospective observation revealed that AEs are frequent in neurosurgical care. The high frequency of human performance deficiencies contributing to AEs shows that there is potential to further eliminate avoidable patient harm. These data can serve as benchmarks when discussing quality-based accreditation and reimbursement in upcoming health care reform.
References
- 1.
- Suliburk JW, Buck QM, Pirko CJ, Massarweh NN, Barshes NR, Singh H, Rosengart TK. Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events. JAMA Netw Open. 2019 Jul 3;2(7):e198067. DOI: 10.1001/jamanetworkopen.2019.8067
