Fig. 13.1
Planning CT (for fusion with MRI) after frame placement of a patient about to receive Gamma Knife radiosurgery for a small metastasis – a large right frontal one has been previously resected. In spite of the neurosurgeon taking care, the right frontal pin has been placed into the bone flap and has depressed it. Fortunately there were no negative sequelae
Adverse events are unintended outcomes of medical treatment that cause patient morbidity, mortality, or prolonged hospital stay (Kohn et al. 2000). Adverse events are either preventable, that is, caused by errors, or non-preventable. Not all errors lead to adverse events; an error which does not cause harm to the patient is referred to as a “near miss” (Reason 1990). Approximately half of all surgical adverse events are preventable (Gawande et al. 1999). In the surgical literature, no universally accepted definition of complications exists. One attempt defines surgical complications as “any undesirable, unintended and direct results of an operation affecting the patient which would not have occurred had the operation gone as well as could reasonably be hoped” (Sokol and Wilson 2008). “Complications occur, whereas errors are committed” according to one commentator (Angelos 2009). Under this definition, if an action or omission during surgery leads to an adverse event, it is considered an error and the adverse event was preventable. In contrast if despite best practices the adverse event occurred anyway, a complication occurred and the adverse event was non-preventable. In reality, most surgeons use the word complications in reference to adverse events that occurred as a result of surgery whether they were preventable or not.
Pearl
Adverse events are unintended outcomes of medical treatment that cause patient morbidity, mortality, or prolonged hospital stay. Preventable adverse events are caused by errors. Non-preventable adverse events are complications of care and treatment.
Errors and complications in neurosurgery have the potential for devastating outcomes and tragic patient harm. The eloquence and frailty of the nervous system structures and their critical role in human function make errors and complications in neurosurgery all the more harmful and regrettable. It is the neurosurgeon’s obligation to take every precaution possible to prevent errors.
13.2 Illustrative Cases
Case 1 (An Error of Execution Occurs and the Patient Is Not Harmed)
A 60- year-old male with a right frontal glioma undergoes craniotomy for resection of tumor. While the nurse is draping the microscope, the surgeon makes use of the time to prepare the bone flap with titanium plates and screws and returns it to a basin on edge of the back table without informing the scrub nurse. A few minutes later the scrub nurse knocks the bone flap basin to the floor. The bone flap is discarded and a cranioplasty fashioned from a titanium mesh. The patient awakens without neurologic deficits and an infection never occurs.
Case 2 (An Error of Planning Occurs and the Patient Is Harmed)
A 45- year-old female presents with aneurysmal subarachnoid hemorrhage on Saturday afternoon. Vascular imaging reveals a 1.2 cm left supraclinoid internal carotid artery. The next best available opportunity for clipping the aneurysm is at 9:00 a.m. Sunday morning. The neurosurgeon specializes in functional neurosurgery and the two aneurysm surgeons are both away until Monday, but she decides to proceed. During the dissection around the aneurysm, an intraoperative rupture occurs and the surgeon struggles for 20 min to obtain proximal control leading to intraoperative hypotension from blood loss and prolonged cerebral ischemia from temporary clipping. Following the surgery, the patient awakens with complete hemiplegia and global aphasia.
Case 3 (No Error Occurs but the Patient Experiences a Complication)
A 70-year-old patient with normal pressure hydrocephalus is admitted to undergo an elective ventriculoperitoneal shunt insertion. The surgeon had recently reviewed the guidelines for prevention of shunt infections and adhered to current best practices including double-gloving and perioperative antibiotics. The surgery goes as planned and sterile technique is maintained throughout the procedure. The patient’s initial postoperative course is uncomplicated and he is discharged on the second postoperative day. Two months later the patient returns with a shunt infection requiring a hospital admission, shunt removal, antibiotics, and eventual reinsertion.
13.3 Detection and Surveillance of Errors
Harvey Cushing, the “father” of modern neurosurgery recognized the importance of learning from errors and sharing them with peers. In a classic paper on the use of bony decompression for treating cerebral herniation, Cushing stated: “Surgical knowledge of value is built up more on the mistakes than on the successes of past experience” (Cushing 1905). Cushing also recognized the importance of strict prospective recording of errors.
There are several methods for detecting errors and adverse events. The most sensitive methods involve direct prospective observation and documentation of clinical care, frequent review of charts, and interviewing caregivers (Stone and Bernstein 2007). An increasing number of surgical practices are incorporating prospective error recording – one general surgery group demonstrated that continuous monitoring of adverse events reduced the number of errors during the study period by more than half (Rebasa et al. 2009). In comparison to prospective error recording, retrospective chart review detects far fewer errors and adverse events. Ten times as many postoperative adverse events following major spinal surgery were discovered when they were recorded prospectively compared to retrospective chart abstraction (Street et al. 2012).
Pearl
The most effective method of error recording is prospective observation and documentation of errors.
Prior to the increased focus on patient safety of the past decade, voluntary reporting was the major method for detecting adverse events. The Joint Commission, an oversight body that accredits hospitals in the United States, recommends voluntary reporting of sentinel events and “never events” such as wrong-site surgery and gossypiboma (retained foreign object), by accredited hospitals (Joint Commission 2012). Voluntary reporting of errors alone has a low detection rate for adverse events, but one advantage of voluntary reporting systems is that they enable systematic reviews of specific events and the development of systems for prevention. The Joint Commission performs root cause analysis on reported sentinel events, a system developed in psychology to identify factors that underlie variations in performance (Wu et al. 2008). Morbidity and mortality rounds are a form voluntary reporting commonly practiced in surgery. Although these rounds only detect a small proportion of adverse events, they are capable of teaching surgical residents to reflect on adverse events and can encourage openness in error reporting among colleagues.
The gold standard for error and adverse event detection and recording is prospective collection and documentation with frequent event review. However, voluntary reporting systems can raise awareness of the most significant errors and adverse events and can allow for analysis and development of systems for prevention.
13.4 Causes of Errors and Adverse Events
All errors can be ultimately attributed to human error in some way. The goal of patient safety initiatives is to minimize the chance of an error becoming an adverse event that harms a patient in some way; this is the error that is blocked from hurting the patient by systems put in place. A useful visible model for errors and adverse events is the Swiss cheese model or cumulative act effect. Many slices of Swiss cheese line up each representing a barrier. When the holes in all the slices line up, an error passes through them causing the error to become an adverse event (Reason 2000). The systems approach to patient safety views errors as inevitable and attempts to reduce the likelihood of systemic factors from contributing to errors and creates barriers for error prevention. The causes of errors and the reasons errors evade prevention can be classified as organization, situational, team, individual, task, and patient factors (Vincent et al. 2000).
Pearl
The systems approach to patient safety views errors as inevitable and attempts to promote the development of systems to create barriers to errors causing harm to patients. The most important step in error prevention is endorsing and embracing a culture of safety.
13.4.1 Organizational Factors
Organizational factors are underlying system conditions that predispose to errors (Vincent et al. 2000). Examples of organizational factors include adequacy of personnel and quality and availability of equipment, scheduling and timing of procedures, and substitution of usual team members with new team members. For instance, in Case A, an organizational policy mandating that the surgeon should inform the nurse when he/she returns the bone flap to the back table could have prevented the bone flap from being knocked to the floor. In neurosurgery, having specialized scrub nurses with experience in neurosurgery is critical for providing safe surgery. Hospitals are obliged to ensure adequate scrub nurse coverage for the types of elective operations that occur during regular working hours and the types of emergencies occurring afterhours.
13.4.2 Situational Factors
Situational factors are work environment conditions such as distractions and interruptions and equipment design elements such as monitors and displays (Bernstein et al. 2003). One study examining the type and timing of pages received by the on-call junior neurosurgery resident found that two-thirds of pages were classified as nonurgent and two-thirds occurred during and potentially interrupted patient care activities (Fargen and Friedman 2012). Several organizational approaches can minimize nonessential interruptions by establishing policies for managing nonurgent ward issues such as doctor’s notes on patient’s charts or specific times during the day for handling nonurgent concerns. Regarding equipment, if surgical equipment fails causing an error or adverse event, the equipment may require redesign. Furthermore, in this situation is the surgeon, hospital, or manufacturer culpable for the adverse event, or all three?
13.4.3 Team Factors
Team factors encompass verbal and written communication among team members, team structure such as leadership and supervision, confidence among team members, and the ability of teams to manage unexpected events (Vincent et al. 2000). In a review of 35 cases of wrong-site neurosurgery, communication breakdown among team members and between hospital departments was determined to be the most prevalent contributing factor to wrong-site neurosurgery (Cohen et al. 2010). In Case A, had the surgeon communicated to the scrub nurse he/she was returning the bone flap, the nurse may have positioned it away from the edge of the table and error could have been prevented.
13.4.4 Individual Factors
Individual factors include mental readiness, technical performance, and fatigue. Individual factors contribute to human errors that may become adverse events if barriers are not in place or are ineffective. Sleep deprivation impairs surgeon concentration and worsens performance (Taffinder et al. 1998). A significant number of wrong-site craniotomies occur during late hours and emergency situations (Cohen et al. 2010). Each surgeon is responsible for recognizing the individual factors that may affect their performance and for developing strategies to cope with fatigue and emergent situations.
13.4.5 Task Factors
Task factors relate to the task at hand including clear protocols and accurate available information. The omission of necessary task steps may be the most common type of human error. In Case B, the surgeon decided to proceed with a difficult aneurysm without proper backup from more experienced colleagues on a weekend (an example of task factors and individual factors). Surgery involves executing many different complex tasks in a coordinated fashion. In order to reduce the likelihood of omitted steps becoming adverse events, one may first determine whether the omission of a step in surgery could harm the patient. Second, decide if a particular step is predisposed to omission in particular. Lastly, develop a method for ensuring that a particular step is performed when necessary. For instance, in spine surgery, to prevent a wrong-level surgery, one should always obtain an intraoperative x-ray (or several as needed) verifying the correct level (Bernstein et al. 2003).
13.4.6 Patient Factors
Patient factors that may contribute to errors in surgery include obesity, anatomical variations, disease severity, and comorbidities. A large body habitus increases the task difficulty of lumbar puncture, increasing the likelihood of inadvertent injury to local structures. The location of certain tumors to eloquent neurologic structures increases the risk of postoperative deficits. Elderly patients experience more preventable adverse events because their comorbidities necessitate more complex care.
13.5 Error Prevention
13.5.1 Endorse a Culture of Safety
Reducing errors and adverse events in health care requires a multifaceted approach. The most important component to patient safety initiative is endorsing a culture of safety. Rather than a shame and blame approach that targets the individual for error culpability, the systems approach encourages learning from errors and ensuring they do not recur through systems-based initiatives. When a health-care professional mentions concerns about danger in the workplace or alerts leadership about an error that took place, their efforts should be commended. Today’s generation of residents needs to experience and support a culture of safety in order to overcome the counterproductive traditional approach of shame and blame.
13.5.2 Improve Error Detection, Measurement and Reporting
In order to identify systemic factors contributing to errors, errors must be detected, measured, reported, and analyzed. The major barrier to error reporting is the existing culture of shame and blame and the public’s view that physicians, especially surgeons, should be flawless. Near misses provide opportunities for analyzing situations where a patient was not harmed but still expose the factors that predispose to potentially devastating errors so the surgeon and the team can learn. For example, suppose a surgeon nearly performed a wrong-site craniotomy but realized at the last minute and no error occurred. The system failures that nearly enabled the error to take place can be scrutinized and future related adverse events can be prevented without casting shame or blame on an individual. The most effective method of detecting and measuring errors is the prospective recording of errors. Although at present, few oversight bodies require mandatory reporting of certain errors, reporting errors and adverse events allows for root cause analysis and future error prevention.
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