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Impact of System Approach and Personal Performance on Preventable Morbidity and Mortality Events in Neurosurgery Patients by Daina Kashiwazaki; Takahiro Tomita; Emiko Hori; Naoki Akioka; Takuya Akai; Satoshi Kuroda is a Medicine article available to read on EtoBox.

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## Purpose: 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. ## Methods: 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. ## Results: 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

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Author

Daina Kashiwazaki; Takahiro Tomita; Emiko Hori; Naoki Akioka; Takuya Akai; Satoshi Kuroda

Publisher

Springer Science and Business Media LLC

Published

2022

Language

EN

Field

Medicine (Health Sciences)