Advertisement

Near Misses in the Intraoperative Brain Suite

  • Cory RoethEmail author
  • Nicoleta Stoicea
  • Sergio D. Bergese
Chapter

Abstract

Despite current patient safety procedures and error reporting systems, errors in medicine still occur and commonly go unreported. A near miss is a type of medical error that is either corrected before it occurs or action is taken to prevent the mistake from causing harm to the patient. Analyzing these near miss scenarios can provide a wealth of educational and training opportunities; however, currently there are scarce examples of near misses available in the neurosurgical literature. The current neurosurgical literature provides near miss scenarios involving difficult intubation and extubation, incorrect drug administration, wrong-level spinal surgery, intraoperative macroglossia, and retained foreign bodies. Analysis of malpractice claims found that spinal neurosurgery had the second highest incidence of errors, outnumbered only by gastrointestinal surgery; clearly the neurosurgical field has yet to devise a system that allows for the consistent and accurate reporting of errors and near misses, considering the sensitive nature of this topic and scarcity of literature. Our systematic review intended to identify the aforementioned cases, discuss the nature of errors (human or device related), and summarize the preemptive measures meant to improve technology and surgical/anesthesia care performance. The neurosurgical community is working on creating limiting errors programs by adapting successful error reporting models.

Keywords

Near miss Preventable errors Mistakes Neurosurgery Error reporting 

Notes

Acknowledgment

We acknowledge the editorial support of Drs. Gurneet Sandhu and Juan Fiorda.

References

  1. 1.
    Rolston JD, Bernstein M. Errors in neurosurgery. Neurosurg Clin N Am. 2015;26(2):149–55.CrossRefGoogle Scholar
  2. 2.
    Fowler DL. Taxonomy of errors: adverse event/near miss analysis. In: Tichansky DS, Morton J, Jones DB, editors. The SAGES manual of quality, outcomes and patient safety. Boston: Springer; 2012. p. 139–45.CrossRefGoogle Scholar
  3. 3.
    Phillips RL. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care. 2004;13(2):121–6.CrossRefGoogle Scholar
  4. 4.
    Elder NC, Dovey SM. Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. J Fam Pract. 2002;51(11):927–32.PubMedGoogle Scholar
  5. 5.
    Bates DW. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29–34.CrossRefGoogle Scholar
  6. 6.
    Weingart SN. Epidemiology of medical error. BMJ. 2000;320(7237):774–7.CrossRefGoogle Scholar
  7. 7.
    Rogers SO, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25–33.CrossRefGoogle Scholar
  8. 8.
    Gibbs VC, et al. Preventable errors in the operating room: retained foreign bodies after surgery—Part I. Curr Probl Surg. 2007;44(5):281–337.CrossRefGoogle Scholar
  9. 9.
    Mahran MA, et al. The recurring problem of retained swabs and instruments. Best Pract Res Clin Obstet Gynaecol. 2013;27(4):489–95.CrossRefGoogle Scholar
  10. 10.
    Devine J, Chutkan N, Norvell DC, Dettori JR. Avoiding wrong site surgery. Spine (Phila Pa 1976). 2010;35(9 Suppl):S28–36.CrossRefGoogle Scholar
  11. 11.
    Bonrath EM, Gordon LE, Grantcharov TP. Characterising ‘near miss’ events in complex laparoscopic surgery through video analysis. BMJ Qual Saf. 2015;24(8):516–21.CrossRefGoogle Scholar
  12. 12.
    Fasting S, Gisvold SE. Serious intraoperative problems a five-year review of 83, 844 anesthetics. Can J Anesth. 2002;49(6):545–53.CrossRefGoogle Scholar
  13. 13.
    Nanji KC, et al. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124(1):25–34.CrossRefGoogle Scholar
  14. 14.
    Gurrieri C, et al. Allergic reactions during anesthesia at a large united states referral center. Anesth Analg. 2011;113(5):1202–12.CrossRefGoogle Scholar
  15. 15.
    Mody MG, et al. The prevalence of wrong level surgery among spine surgeons. Spine. 2008;33(2):194–8.CrossRefGoogle Scholar
  16. 16.
    Boström J, et al. Prospective collection and analysis of error data in a neurosurgical clinic. Clin Neurol Neurosurg. 2010;112(4):314–9.CrossRefGoogle Scholar
  17. 17.
    Jhawar BS, et al. Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine. 2007;7(5):467–72.CrossRefGoogle Scholar
  18. 18.
    The Joint Commission. Universal protocol. www.jointcommission.org/standards_information/up.aspx. Accessed 2 Apr 2018.
  19. 19.
    Cohen FL, et al. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461–73.CrossRefGoogle Scholar
  20. 20.
    Clarke JR, et al. Getting surgery right. Ann Surg. 2007;246(3):395–405.CrossRefGoogle Scholar
  21. 21.
    Kuhnert SM, et al. Postoperative macroglossia. Anesth Analg. 1999;88(1):220–3.PubMedGoogle Scholar
  22. 22.
    Lam AM, Vavilala MS. Macroglossia: compartment syndrome of the tongue? Anesthesiology. 2000;92(6):1832.CrossRefGoogle Scholar
  23. 23.
    Cormack J, Karna S. Macroglossia during awake craniotomy: a near miss. J Neurosurg Anesthesiol. 2017;30(4):383–4.  https://doi.org/10.1097/ana.0000000000000465.CrossRefGoogle Scholar
  24. 24.
    Olivar H, et al. Subarachnoid lumbar drains: a case series of fractured catheters and a near miss. Can J Anesth. 2007;54(10):829–34.CrossRefGoogle Scholar
  25. 25.
    Oshino S, Kishima H, Ohnishi Y, Iwatsuki K, Saitoh Y. “Do Not Follow the Tail”: A Practical Approach to Remove a Sheared Lumbar Catheter Fragment Avoiding Its Migration into the Spinal Canal. World Neurosurg. 2016;87:266–8.CrossRefGoogle Scholar
  26. 26.
    Naito N, Abe M, Fukasawa M, Takeshi A. Pulmonary embolism by a foreign body that migrated in the inferior vena cava during lumbar spine surgery. BMJ Case Rep. 2014;2014:bcr2014205423.  https://doi.org/10.1136/bcr-2014-205423.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Feldman DL. Prevention of retained surgical items. Mt Sinai J Med. 2011;78(6):865–71.CrossRefGoogle Scholar
  28. 28.
    Stone S, Bernstein M. Prospective error recording in surgery. Neurosurgery. 2007;60(6):1075–82.CrossRefGoogle Scholar
  29. 29.
    Grant MJC, Larsen GY. Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. J Nurs Care Qual. 2007;22(3):213–21.CrossRefGoogle Scholar
  30. 30.
    Barach P. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320(7237):759–63.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Cory Roeth
    • 1
    • 2
    Email author
  • Nicoleta Stoicea
    • 2
  • Sergio D. Bergese
    • 2
    • 3
  1. 1.Boonshoft School of MedicineDaytonUSA
  2. 2.Department of AnesthesiologyThe Ohio State University Wexner Medical CenterColumbusUSA
  3. 3.Department of Neurological SurgeryThe Ohio State University Wexner Medical CenterColumbusUSA

Personalised recommendations