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

Authors

  • Aashray K. Gupta,

    1. South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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  • Sasha K. Stewart,

    Corresponding author
    1. South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
    • Correspondence

      Ms Sasha K. Stewart, South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, P.O. Box 3115, Melbourne Street, North Adelaide, SA 5006, Australia. Email: sasha.stewart@surgeons.org

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  • Kimberley Cottell,

    1. South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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  • Glenn A. J. McCulloch,

    1. South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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  • Wendy Babidge,

    1. University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
    2. Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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  • Guy J. Maddern

    1. University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
    2. Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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  • A. K. Gupta; S. K. Stewart BSc, GDipPubHlth; K. Cottell BMedSc; G. A. J. McCulloch FRCS (Ed.), FRACS; W. Babidge PhD; G. J. Maddern PhD, FRACS.

Abstract

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.

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