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Analyzing Complications

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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.

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References

  1. Stefl ME. To err is human: building a safer health system in 1999. Front Health Serv Manag. 2001;18(1):1–2.

    Article  CAS  Google 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.

    Article  CAS  PubMed  Google Scholar 

  4. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477–81.

    Article  CAS  PubMed  Google Scholar 

  5. Porter ME. A strategy for health care reform—toward a value-based system. N Engl J Med. 2009;361(2):109–12.

    Article  CAS  PubMed  Google 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.

    Article  PubMed  Google 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.

    PubMed  PubMed Central  CAS  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  Google Scholar 

  13. Campbell WB. Surgical morbidity and mortality meetings. Ann R Coll Surg Engl. 1988;70(6):363–5.

    PubMed  PubMed Central  CAS  Google 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.

    Article  PubMed  Google 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.

    Article  CAS  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  Google 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 311

    Article  PubMed  Google 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.

    Article  PubMed  Google 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.

    PubMed  Google 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.

    Article  CAS  PubMed  Google 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.

    PubMed  PubMed Central  CAS  Google 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.

    Article  PubMed  Google 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.

    Article  Google 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.

    Article  PubMed  Google 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.

    Article  CAS  PubMed  PubMed Central  Google 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.

    Article  CAS  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  Google Scholar 

  32. Adams R, Warner P, Hubbard B, Goulding T. Decreasing turnaround time between general surgery cases. JONA. 2004;34(3):140–8.

    Article  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  Google 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.

    Article  PubMed  PubMed Central  Google 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.

    Article  CAS  PubMed  Google Scholar 

  40. Hales BM, Pronovost PJ. The checklist—a tool for error management and performance improvement. J Crit Care. 2006;21(3):231–5.

    Article  PubMed  Google 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.

    PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  CAS  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Correspondence to Aman B. Patel M.D. .

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Karhade, A.V., Koch, M.J., Stapleton, C.J., Patel, A.B. (2018). Analyzing Complications. In: Gandhi, C., Prestigiacomo, C. (eds) Cerebrovascular and Endovascular Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-319-65206-1_4

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  • DOI: https://doi.org/10.1007/978-3-319-65206-1_4

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-65204-7

  • Online ISBN: 978-3-319-65206-1

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