Analyzing Complications
Chapter
First Online:
Abstract
The systematic analysis of complications, errors, and adverse events is a necessary component of healthcare delivery. Driven by clinical, financial, and legislative pressures, this analysis and subsequent action can result in an improvement in overall hospital performance metrics and patient outcomes. Herein, we review the history of quality improvement in surgery and provide an overview of business intelligence strategies and quality improvement methodologies that can be applied to surgery in general and cerebrovascular and endovascular neurosurgery in specific.
References
- 1.Stefl ME. To err is human: building a safer health system in 1999. Front Health Serv Manag. 2001;18(1):1–2.CrossRefGoogle Scholar
- 2.Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–69.Google Scholar
- 3.Porter ME, Lee TH. Why strategy matters now. N Engl J Med. 2015;372(18):1681–4.CrossRefPubMedGoogle Scholar
- 4.Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477–81.CrossRefPubMedGoogle Scholar
- 5.Porter ME. A strategy for health care reform—toward a value-based system. N Engl J Med. 2009;361(2):109–12.CrossRefPubMedGoogle Scholar
- 6.Bekelis K, McGirt MJ, Parker SL, et al. The present and future of quality measures and public reporting in neurosurgery. Neurosurg Focus. 2015;39(6):E3.CrossRefPubMedGoogle Scholar
- 7.Hirsch JA, Leslie-Mazwi TM, Patel AB, et al. MACRA: background, opportunities and challenges for the neurointerventional specialist. J Neurointerv Surg. 2016;8(8):868–74.Google Scholar
- 8.McCarthy M. Controversial online “scorecard” shows complication rates of 17,000 US surgeons. BMJ (Clinical Research ed). 2015;351:h3873.Google Scholar
- 9.Luce JM, Bindman AB, Lee PR. A brief history of health care quality assessment and improvement in the United States. West J Med. 1994;160(3):263–8.PubMedPubMedCentralGoogle Scholar
- 10.Chang A, Schyve PM, Croteau RJ, O’Leary DS, Loeb JM. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care. 2005;17(2):95–105.CrossRefPubMedGoogle Scholar
- 11.Hutter MM, Rowell KS, Devaney LA, et al. Identification of surgical complications and deaths: an assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program. J Am Coll Surg. 2006;203(5):618–24.CrossRefPubMedGoogle Scholar
- 12.Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RA. A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. J Surg Res. 2009;153(1):95–104.CrossRefPubMedGoogle Scholar
- 13.Campbell WB. Surgical morbidity and mortality meetings. Ann R Coll Surg Engl. 1988;70(6):363–5.PubMedPubMedCentralGoogle Scholar
- 14.Mok PS, Tan EY, Baerlocher MO, Athreya S. The role of morbidity and mortality meetings in interventional radiology. Eur J Radiol. 2012;81(11):3344–7.CrossRefPubMedGoogle Scholar
- 15.Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290(21):2838–42.CrossRefPubMedGoogle Scholar
- 16.Murayama KM, Derossis AM, DaRosa DA, Sherman HB, Fryer JP. A critical evaluation of the morbidity and mortality conference. Am J Surg. 2002;183(3):246–50.CrossRefPubMedGoogle Scholar
- 17.Anderson CI, Nelson CS, Graham CF, et al. Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. J Surg Res. 2012;177(1):43–8.CrossRefPubMedGoogle Scholar
- 18.Bilimoria KY, Kmiecik TE, DaRosa DA, et al. Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. Arch Surg. 2009;144(4):305–11; discussion 311CrossRefPubMedGoogle Scholar
- 19.McVeigh TP, Waters PS, Murphy R, O’Donoghue GT, McLaughlin R, Kerin MJ. Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference. J Am Coll Surg. 2013;216(1):50–6.CrossRefPubMedGoogle Scholar
- 20.Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg. 2009;250(3):363–76.PubMedGoogle Scholar
- 21.Nicolay C, Purkayastha S, Greenhalgh A, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg. 2012;99(3):324–35.CrossRefPubMedGoogle Scholar
- 22.Shortell SM, O’Brien JL, Carman JM, et al. Assessing the impact of continuous quality improvement/total quality management: concept versus implementation. Health Serv Res. 1995;30(2):377.PubMedPubMedCentralGoogle Scholar
- 23.Ferguson TB Jr, Peterson ED, Coombs LP, et al. Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: a randomized controlled trial. JAMA. 2003;290(1):49–56.CrossRefPubMedGoogle Scholar
- 24.Stanford J, Swaney-Berghoff L, Recht K, Orsagh-Yentis D. Improved cardiac surgical outcomes with use of total quality management. J Clin Outcomes Manage. 2009;16(9):405–9.Google Scholar
- 25.Moen R, Norman C. Evolution of the PDCA cycle. 2006.Google Scholar
- 26.Zack J. Zeroing in on zero tolerance for central line-associated bacteremia. Am J Infect Control. 2008;36(10):S176. e171–2.CrossRefGoogle Scholar
- 27.Goodney PP, Chang RW, Cronenwett JL. A percutaneous arterial closure protocol can decrease complications after endovascular interventions in vascular surgery patients. J Vasc Surg. 2008;48(6):1481–8.CrossRefPubMedGoogle Scholar
- 28.Benneyan J, Lloyd R, Plsek P. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. 2003;12(6):458–64.CrossRefPubMedPubMedCentralGoogle Scholar
- 29.Duclos A, Touzet S, Soardo P, Colin C, Peix J, Lifante J. Quality monitoring in thyroid surgery using the Shewhart control chart. Br J Surg. 2009;96(2):171–4.CrossRefPubMedGoogle Scholar
- 30.Ryckman FC, Schoettker PJ, Hays KR, et al. Reducing surgical site infections at a Pediatric Academic Medical Center. Jt Comm J Qual Patient Saf. 2009;35(4):192–8.CrossRefPubMedGoogle Scholar
- 31.Gamal Aboelmaged M. Six sigma quality: a structured review and implications for future research. Int J Qual Reliab Manag. 2010;27(3):268–317.CrossRefGoogle Scholar
- 32.Adams R, Warner P, Hubbard B, Goulding T. Decreasing turnaround time between general surgery cases. JONA. 2004;34(3):140–8.CrossRefGoogle Scholar
- 33.Frankel HL, Crede WB, Topal JE, Roumanis SA, Devlin MW, Foley AB. Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU. J Am Coll Surg. 2005;201(3):349–58.CrossRefPubMedGoogle Scholar
- 34.Muder RR, Cunningham C, McCray E, et al. Implementation of an industrial systems-engineering approach to reduce the incidence of methicillin-resistant Staphylococcus aureus infection. Infect Control Hosp Epidemiol. 2008;29(08):702–8.CrossRefPubMedGoogle Scholar
- 35.Niemeijer GC, Trip A, Ahaus KT, Does RJ, Wendt KW. Quality in trauma care: improving the discharge procedure of patients by means of Lean Six Sigma. J Trauma Acute Care Surg. 2010;69(3):614–9.CrossRefGoogle Scholar
- 36.Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002;37(6):1553–81.CrossRefPubMedPubMedCentralGoogle Scholar
- 37.Risser DT, Simon R, Rice MM, Salisbury ML. A structured teamwork system to reduce clinical errors. In: Error reduction in health care: a systems approach to improving patient safety. New York: Jossey-Bass; 1999. p. 230–40.Google Scholar
- 38.Levin L, Gardner-Bonneau DJ. What is iatrogenics, and why don’t ergonomists know? Ergon Des. 1993;1(3):18–20.Google Scholar
- 39.McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care. 2009;18(2):109–15.CrossRefPubMedGoogle Scholar
- 40.Hales BM, Pronovost PJ. The checklist—a tool for error management and performance improvement. J Crit Care. 2006;21(3):231–5.CrossRefPubMedGoogle Scholar
- 41.Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient care. Med J Aust. 2004;181:428–31.PubMedGoogle Scholar
- 42.Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32(10):2014–20.CrossRefPubMedGoogle Scholar
- 43.Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71–5.CrossRefPubMedGoogle Scholar
- 44.Bergs J, Hellings J, Cleemput I, et al. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg. 2014;101(3):150–8.CrossRefPubMedGoogle Scholar
- 45.Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17(5):470–8.CrossRefPubMedGoogle Scholar
- 46.Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320(7237):745–9.CrossRefPubMedPubMedCentralGoogle Scholar
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