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Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation()

INTRODUCTION: Adverse events in surgery are a relevant cause of costs, disability, or death, and their incidence is a key quality indicator that plays an important role in the future of health care. In neurosurgery, little is known about the frequency of adverse events and the contribution of human...

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Autores principales: Meyer, Hanno S., Wagner, Arthur, Obermueller, Thomas, Negwer, Chiara, Wostrack, Maria, Krieg, Sandro, Gempt, Jens, Meyer, Bernhard
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Elsevier 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9560675/
https://www.ncbi.nlm.nih.gov/pubmed/36248119
http://dx.doi.org/10.1016/j.bas.2021.100853
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author Meyer, Hanno S.
Wagner, Arthur
Obermueller, Thomas
Negwer, Chiara
Wostrack, Maria
Krieg, Sandro
Gempt, Jens
Meyer, Bernhard
author_facet Meyer, Hanno S.
Wagner, Arthur
Obermueller, Thomas
Negwer, Chiara
Wostrack, Maria
Krieg, Sandro
Gempt, Jens
Meyer, Bernhard
author_sort Meyer, Hanno S.
collection PubMed
description INTRODUCTION: Adverse events in surgery are a relevant cause of costs, disability, or death, and their incidence is a key quality indicator that plays an important role in the future of health care. In neurosurgery, little is known about the frequency of adverse events and the contribution of human error. RESEARCH QUESTION: To determine the incidence, nature and severity of adverse events in neurosurgery, and to investigate the contribution of human error. MATERIAL AND METHODS: Prospective observation of all adverse events occurring at an academic neurosurgery referral center focusing on neuro-oncology, cerebrovascular and spinal surgery. All 4176 inpatients treated between September 2019 and September 2020 were included. Adverse events were recorded daily and their nature, severity and a potential contribution of human error were evaluated weekly by all senior neurosurgeons of the department. RESULTS: 25.0% of patients had at least one adverse event. In 25.9% of these cases, the major adverse event was associated with human error, mostly with execution (18.3%) or planning (5.6%) deficiencies. 48.8% of cases with adverse events were severe (≥SAVES-v2 grade 3). Patients with multiple adverse events (8.6%) had more severe adverse events (67.6%). Adverse events were more severe in cranial than in spinal neurosurgery (57.6 vs. 39.4%). DISCUSSION AND CONCLUSION: Adverse events occur frequently in neurosurgery. These data can serve as benchmarks when discussing quality-based accreditation and reimbursement in upcoming health care reforms. The high frequency of human performance deficiencies contributing to adverse events shows that there is potential to further eliminate avoidable patient harm.
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spelling pubmed-95606752022-10-14 Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation() Meyer, Hanno S. Wagner, Arthur Obermueller, Thomas Negwer, Chiara Wostrack, Maria Krieg, Sandro Gempt, Jens Meyer, Bernhard Brain Spine Article INTRODUCTION: Adverse events in surgery are a relevant cause of costs, disability, or death, and their incidence is a key quality indicator that plays an important role in the future of health care. In neurosurgery, little is known about the frequency of adverse events and the contribution of human error. RESEARCH QUESTION: To determine the incidence, nature and severity of adverse events in neurosurgery, and to investigate the contribution of human error. MATERIAL AND METHODS: Prospective observation of all adverse events occurring at an academic neurosurgery referral center focusing on neuro-oncology, cerebrovascular and spinal surgery. All 4176 inpatients treated between September 2019 and September 2020 were included. Adverse events were recorded daily and their nature, severity and a potential contribution of human error were evaluated weekly by all senior neurosurgeons of the department. RESULTS: 25.0% of patients had at least one adverse event. In 25.9% of these cases, the major adverse event was associated with human error, mostly with execution (18.3%) or planning (5.6%) deficiencies. 48.8% of cases with adverse events were severe (≥SAVES-v2 grade 3). Patients with multiple adverse events (8.6%) had more severe adverse events (67.6%). Adverse events were more severe in cranial than in spinal neurosurgery (57.6 vs. 39.4%). DISCUSSION AND CONCLUSION: Adverse events occur frequently in neurosurgery. These data can serve as benchmarks when discussing quality-based accreditation and reimbursement in upcoming health care reforms. The high frequency of human performance deficiencies contributing to adverse events shows that there is potential to further eliminate avoidable patient harm. Elsevier 2021-12-20 /pmc/articles/PMC9560675/ /pubmed/36248119 http://dx.doi.org/10.1016/j.bas.2021.100853 Text en © 2021 The Authors https://creativecommons.org/licenses/by-nc-nd/4.0/This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
spellingShingle Article
Meyer, Hanno S.
Wagner, Arthur
Obermueller, Thomas
Negwer, Chiara
Wostrack, Maria
Krieg, Sandro
Gempt, Jens
Meyer, Bernhard
Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation()
title Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation()
title_full Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation()
title_fullStr Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation()
title_full_unstemmed Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation()
title_short Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation()
title_sort assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. a prospective observation()
topic Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9560675/
https://www.ncbi.nlm.nih.gov/pubmed/36248119
http://dx.doi.org/10.1016/j.bas.2021.100853
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