Key points

Introduction

Because of its high level of complexity, neurosurgery is a high-risk specialty, and improving patient outcomes has remained central in its spectrum of academic pursuits. However, only recently has there been a growing recognition of the need for a systematic approach for improving the safety and reducing adverse events for patients. This change has been in part caused by growing recognition of the pervasive nature of medical errors, adverse events, and complications that reduce patient safety, along with the growth in the body of literature describing their impacts, as well as economic and regulatory pressures from health care governing bodies. Independent of these pressures, neurosurgery clinicians have always taken pride in being providers who carry a strong sense of personal responsibility for their patients. With any errors or bad outcomes being considered as personal failings, it has frequently been considered that the solution to these problems is simply to work harder, believing that if clinicians do their best not to make a mistake, mistakes would not occur. However, it has become clear that this is not the case, and that the only way to deliver safe care is to place fallible but conscientious people in systems of care that support them with the knowledge and the tools to identify and anticipate adverse events and prevent them before they can harm patients. At the root of this is the need to change the neurosurgical culture: to practice medicine with patient safety as a priority within systems that help clinicians understand, identify, and prevent errors in a systematic fashion, with a focus on solutions rooted in systems-based approaches ( Fig. 1 ).

Patient safety ecosystem. IT, information technology.

( From Berger MS, Wachter RM, Greysen SR, et al. Changing our culture to advance patient safety: the 2013 AANS presidential address. J Neurosurg 2013;119(6):1361; with permission.)

Introduction

Because of its high level of complexity, neurosurgery is a high-risk specialty, and improving patient outcomes has remained central in its spectrum of academic pursuits. However, only recently has there been a growing recognition of the need for a systematic approach for improving the safety and reducing adverse events for patients. This change has been in part caused by growing recognition of the pervasive nature of medical errors, adverse events, and complications that reduce patient safety, along with the growth in the body of literature describing their impacts, as well as economic and regulatory pressures from health care governing bodies. Independent of these pressures, neurosurgery clinicians have always taken pride in being providers who carry a strong sense of personal responsibility for their patients. With any errors or bad outcomes being considered as personal failings, it has frequently been considered that the solution to these problems is simply to work harder, believing that if clinicians do their best not to make a mistake, mistakes would not occur. However, it has become clear that this is not the case, and that the only way to deliver safe care is to place fallible but conscientious people in systems of care that support them with the knowledge and the tools to identify and anticipate adverse events and prevent them before they can harm patients. At the root of this is the need to change the neurosurgical culture: to practice medicine with patient safety as a priority within systems that help clinicians understand, identify, and prevent errors in a systematic fashion, with a focus on solutions rooted in systems-based approaches ( Fig. 1 ).

Patient safety ecosystem. IT, information technology.

( From Berger MS, Wachter RM, Greysen SR, et al. Changing our culture to advance patient safety: the 2013 AANS presidential address. J Neurosurg 2013;119(6):1361; with permission.)

Modern patient safety movement

In the past, it was a common belief that American health care was very safe. Although high-profile cases of adverse events in health care were widely reported, such as the cases of Libby Zion and Betsy Lehman, they were frequently seen as rare failures by individual practitioners. However, reports such as the Harvard Medical Practice Study in 1991 showed that adverse events in health care were more common than was ever anticipated. In addition, early leaders in the field, such as Lucian Leape, introduced the concept that errors in medicine were systems-based problems, and not just individual failings. Then a landmark moment in health care safety came with the Institute of Medicine (IOM) report in 1999, estimating that up to 100,000 patients die every year as a direct result of medical errors, and that this was equivalent to a jumbo jet crashing every day of the year. The IOM’s report was shocking, and it became clear that errors and adverse events were more common and their impact larger than had previously been realized.

Errors and adverse events

With widespread sentiment that something needed to be done, tackling the problem first required a systematic effort to identify, categorize, and analyze adverse events and health care errors. Within neurosurgery, a recent review from Gawande’s group systematically reviewed the literature to describe the patterns of adverse events encountered within neurosurgery. Looking across different subspecialties, their report categorized adverse events based on their contributing factors, including surgical technique, technology, and communication. For errors in neurosurgery, Oremakinde and Bernstein reported on their experience of prospective collecting errors that occurred around operative cases. They confirmed that errors occurred much more frequently than was previously thought, with at least 1 error in almost every case. Furthermore, they described a method of organizing errors into types of errors, which include those that are technical, involving contamination, equipment failure, or caused by communication, with errors further characterized by their severity and clinical impact. These studies show the complexity of the factors contributing to patient safety and the adverse events that threaten patients.