Potentially avoidable issues in neurosurgical mortality cases in Australia: identification and improvements

• Published in: ANZ journal of surgery Vol. 87; no. 1-2; pp. 86 - 91
• Main Authors: Gupta, Aashray K., Stewart, Sasha K., Cottell, Kimberley, McCulloch, Glenn A. J., Babidge, Wendy, Maddern, Guy J.
• Format: Journal Article
• Language: English
• Published: Melbourne Wiley Publishing Asia Pty Ltd 01-01-2017; Blackwell Publishing Ltd
• Subjects: audit; Australia - epidemiology; avoidable; delay treatment; Humans; Medical Audit; Mortality; Neurosurgery; Neurosurgical Procedures - mortality; Peer Review - methods; Quality Improvement; Quality of care; Retrospective Studies; Survival Rate - trends; mortality; neurosurgery; audit; avoidable; delay treatment
• ISSN: 1445-1433; 1445-2197
• DOI: 10.1111/ans.13542

Background
Mortality rates are commonly used to evaluate the quality of surgical care; however, a large proportion of surgical deaths are unavoidable. Examination of the potentially avoidable issues in surgical deaths can provide a strong basis for quality improvement. Using data from a well‐established and comprehensive national surgical mortality audit, we sought to identify the most common avoidable factors in neurosurgical deaths, focusing on the lessons that can be learnt.
Methods
This study analysed data from a peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2014, focusing on neurosurgery cases with identified areas for improvement in patient management. In the 6% of neurosurgical cases that had clinical incidents, there were 193 clinical events identified. These were first categorized based on the perioperative stage (pre‐, intra‐ or postoperative) followed by thematic analysis within each stage.
Results
The study found preoperative issues to be the most common (n = 107) followed by postoperative issues (n = 31) and intraoperative issues (n = 29). The most common theme was inadequate assessment (n = 65) followed by poor communication (at any stage of treatment) (n = 26).
Conclusion
Neurosurgical cases with potentially avoidable mortality constitute a small but important subset. Avoidable contributors to mortality occurred most frequently at the preoperative stage, most commonly relating to inadequate assessment and delays. These findings can inform various stakeholders to improve the quality and safety of surgical care.