Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
Acta Neurochir (Wien). 2022 Nov;164(11):2811-2818. doi: 10.1007/s00701-022-05357-w. Epub 2022 Aug 31.
Adverse events in neurosurgery are a serious problem. The approach for seeking solutions for adverse events has shifted from a personal approach to a systemic approach. However, to some extent, preventable morbidity events could be related to personal performance. This study aimed to clarify the impact of personal performance and systematic failure on the occurrence of morbidity and mortality events in neurosurgery patients.
All morbidity and mortality conference data stored within our department over a 9-year period were analyzed. There were 4580 admitted patients and 3262 surgical procedures performed. We performed a three-step classification of morbidity and mortality events based on the possibility of prevention, root of the event, and personal or systemic issues.
As a result of the first step, 214 preventable and 278 unpreventable events were identified. Of the preventable events, two mortality and 212 morbidity events were analyzed. In the second step, 155 (72.4%), 34 (15.9%), 13 (6.1%), and 12 (5.6%) events were categorized as technical complications, critical events, judgment errors, and human factors, respectively. There were 179 events (83.6%) classified as personal performance issues and 35 events (16.4%) as systemic issues. The ratio of personal performance to systemic issues varied widely, with significant differences among the four categories (P < 0.01).
Among neurosurgery patients who have preventable morbidity, issues related to personal performance were more frequent than systemic issues. Efforts to improve systems should be unwavering. However, the personal responsibility of neurosurgeons to avoid preventable complications should not be ignored.
神经外科的不良事件是一个严重的问题。寻找不良事件解决方案的方法已经从个人方法转变为系统方法。然而，在某种程度上，可预防的发病率事件可能与个人表现有关。本研究旨在阐明个人表现和系统故障对神经外科患者发病率和死亡率事件发生的影响。
分析了我们科室 9 年来所有的发病率和死亡率会议数据。共有 4580 名住院患者和 3262 例手术。我们根据预防的可能性、事件的根源以及个人或系统问题对发病率和死亡率事件进行了三步分类。
第一步的结果确定了 214 例可预防和 278 例不可预防的事件。在可预防的事件中，对 2 例死亡和 212 例发病事件进行了分析。在第二步中，分别将 155 例（72.4%）、34 例（15.9%）、13 例（6.1%）和 12 例（5.6%）事件归类为技术并发症、危急事件、判断错误和人为因素。有 179 例（83.6%）事件被归类为个人表现问题，35 例（16.4%）事件为系统问题。个人表现与系统问题的比例差异很大，四个类别之间存在显著差异（P<0.01）。
在可预防发病率的神经外科患者中，与个人表现相关的问题比系统问题更常见。改进系统的努力应坚定不移。然而，神经外科医生避免可预防并发症的个人责任不应被忽视。
