Patient safety movement in neurological surgery: the current state and future directions

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  • 1 Departments of Neurological Surgery and
  • 2 Medicine, University of California, San Francisco, California
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Contributor Notes

Correspondence Sujatha Sankaran: sujatha.sankaran@ucsf.edu.

INCLUDE WHEN CITING Published online October 4, 2019; DOI: 10.3171/2019.7.JNS191505.

Disclosures Dr. Wachter is a consultant for PatientSafe Solutions, EarlySense, Amino.com, Commure, Forward, and Teledoc; has direct stock ownership in Smart Patients; is an employee of Accuity and The Doctors Company; owns CareWeb; receives royalties from Lippincott, Williams & Wilkins, John Wiley & Sons, and McGraw-Hill; and receives monies from the US Agency for Healthcare Research and Quality.

  • 1

    Ahmed M, Arora S, Russ S, Darzi A, Vincent C, Sevdalis N: Operation debrief: a SHARP improvement in performance feedback in the operating room. Ann Surg 258:958963, 2013

    • Search Google Scholar
    • Export Citation
  • 2

    Ahmed M, Sevdalis N, Paige J, Paragi-Gururaja R, Nestel D, Arora S: Identifying best practice guidelines for debriefing in surgery: a tri-continental study. Am J Surg 203:523529, 2012

    • Search Google Scholar
    • Export Citation
  • 3

    Auerbach AD, Wachter RM, Cheng HQ, Maselli J, McDermott M, Vittinghoff E, : Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med 170:20042010, 2010

    • Search Google Scholar
    • Export Citation
  • 4

    Banz A, Clark A, Agoris C, Imam M, Tran ND: HCP-22. Topically applied vancomycin powder reduces the rate of surgical site infection in patients undergoing craniotomies for primary brain tumors. Neuro Oncol 17 (Suppl 5):v106–v106

    • Search Google Scholar
    • Export Citation
  • , 2015 (Abstract)

  • 5

    Bartz-Kurycki MA, Anderson KT, Abraham JE, Masada KM, Wang J, Kawaguchi AL, : Debriefing: the forgotten phase of the surgical safety checklist. J Surg Res 213:222227, 2017

    • Search Google Scholar
    • Export Citation
  • 6

    Barzallo Salazar MJ, Minkoff H, Bayya J, Gillett B, Onoriode H, Weedon J, : Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg 219:10011007, 2014

    • Search Google Scholar
    • Export Citation
  • 7

    Berger MS, Wachter RM, Greysen SR, Lau CY: Changing our culture to advance patient safety: the 2013 AANS Presidential Address. J Neurosurg 119:13591369, 2013

    • Search Google Scholar
    • Export Citation
  • 8

    Bergs J, Hellings J, Cleemput I, Zurel Ö, De Troyer V, Van Hiel M, : Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg 101:150158, 2014

    • Search Google Scholar
    • Export Citation
  • 9

    Bernardo A: Virtual reality and simulation in neurosurgical training. World Neurosurg 106:10151029, 2017

  • 10

    Bilotta F, Lauretta MP, Borozdina A, Mizikov VM, Rosa G: Postoperative delirium: risk factors, diagnosis and perioperative care. Minerva Anestesiol 79:10661076, 2013

    • Search Google Scholar
    • Export Citation
  • 11

    Bina RW, Lemole GM Jr, Dumont TM: On resident duty hour restrictions and neurosurgical training: review of the literature. J Neurosurg 124:842848, 2016

    • Search Google Scholar
    • Export Citation
  • 12

    Codman E: A Study in Hospital Efficiency: The First Five Years. Boston: Thomas Todd Co, 1916

  • 13

    Dasenbrock HH, Clarke MJ, Witham TF, Sciubba DM, Gokaslan ZL, Bydon A: The impact of provider volume on the outcomes after surgery for lumbar spinal stenosis. Neurosurgery 70:13461354, 2012

    • Search Google Scholar
    • Export Citation
  • 14

    Dasenbrock HH, Liu KX, Devine CA, Chavakula V, Smith TR, Gormley WB, : Length of hospital stay after craniotomy for tumor: a National Surgical Quality Improvement Program analysis. Neurosurg Focus 39(6):E12, 2015

    • Search Google Scholar
    • Export Citation
  • 15

    Davies JM, Ozpinar A, Lawton MT: Volume-outcome relationships in neurosurgery. Neurosurg Clin N Am 26:207218, viii, 2015

  • 16

    Donabedian A: The end results of health care: Ernest Codman’s contribution to quality assessment and beyond. Milbank Q 67:233267, 1989

    • Search Google Scholar
    • Export Citation
  • 17

    Donabedian A: Evaluating the quality of medical care. Milbank Mem Fund Q 44:166206, 1966

  • 18

    Donroe JH, Holt SR, Tetrault JM: Caring for patients with opioid use disorder in the hospital. CMAJ 188:12321239, 2016

  • 19

    Ebbens MM, Gombert-Handoko KB, Al-Dulaimy M, van den Bemt PMLA, Wesselink EJ: Risk factors for medication errors at admission in preoperatively screened patients. Pharmacoepidemiol Drug Saf 27:272278, 2018

    • Search Google Scholar
    • Export Citation
  • 20

    Fargen KM, Velat GJ, Lawson MF, Firment CS, Mocco J, Hoh BL: Enhanced staff communication and reduced near-miss errors with a neurointerventional procedural checklist. J Neurointerv Surg 5:497500, 2013

    • Search Google Scholar
    • Export Citation
  • 21

    Flanigan PM, Jahangiri A, Weinstein D, Dayani F, Chandra A, Kanungo I, : Postoperative delirium in glioblastoma patients: risk factors and prognostic implications. Neurosurgery 83:11611172, 2018

    • Search Google Scholar
    • Export Citation
  • 22

    Graham KL, Marcantonio ER, Huang GC, Yang J, Davis RB, Smith CC: Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. J Gen Intern Med 28:986993, 2013

    • Search Google Scholar
    • Export Citation
  • 23

    Grasu RM, Cata JP, Dang AQ, Tatsui CE, Rhines LD, Hagan KB, : Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis. J Neurosurg Spine 29:588598, 2018

    • Search Google Scholar
    • Export Citation
  • 24

    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, Dellinger EP, : A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491499, 2009

    • Search Google Scholar
    • Export Citation
  • 25

    Jhawar BS, Mitsis D, Duggal N: Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine 7:467472, 2007

  • 26

    Liao JC, Chiu PY, Chen WJ, Chen LH, Niu CC: Surgical outcomes after instrumented lumbar surgery in patients of eighty years of age and older. BMC Musculoskelet Disord 17:402, 2016

    • Search Google Scholar
    • Export Citation
  • 27

    Ling ML, Apisarnthanarak A, Jaggi N, Harrington G, Morikane K, Thu TA, : APSIC guide for prevention of central line associated bloodstream infections (CLABSI). Antimicrob Resist Infect Control 5:16, 2016

    • Search Google Scholar
    • Export Citation
  • 28

    Lukasiewicz AM, Grant RA, Basques BA, Webb ML, Samuel AM, Grauer JN: Patient factors associated with 30-day morbidity, mortality, and length of stay after surgery for subdural hematoma: a study of the American College of Surgeons National Surgical Quality Improvement Program. J Neurosurg 124:760766, 2016

    • Search Google Scholar
    • Export Citation
  • 29

    Magill ST, Wang DD, Rutledge WC, Lau D, Berger MS, Sankaran S, : Changing operating room culture: implementation of a postoperative debrief and improved safety culture. World Neurosurg 107:597603, 2017

    • Search Google Scholar
    • Export Citation
  • 30

    Michalak SM, Rolston JD, Lawton MT: Prospective, multidisciplinary recording of perioperative errors in cerebrovascular surgery: is error in the eye of the beholder? J Neurosurg 124:17941804, 2016

    • Search Google Scholar
    • Export Citation
  • 31

    Neily J, Mills PD, Lee P, Carney B, West P, Percarpio K, : Medical team training and coaching in the Veterans Health Administration; assessment and impact on the first 32 facilities in the programme. Qual Saf Health Care 19:360364, 2010

    • Search Google Scholar
    • Export Citation
  • 32

    Neuhauser D: Ernest Amory Codman MD. Qual Saf Health Care 11:104105, 2002

  • 33

    Noimark D: Predicting the onset of delirium in the post-operative patient. Age Ageing 38:368373, 2009

  • 34

    Oravec CS, Motiwala M, Reed K, Kondziolka D, Barker FG II, Michael LM II, : Big data research in neurosurgery: a critical look at this popular new study design. Neurosurgery 82:728746, 2018

    • Search Google Scholar
    • Export Citation
  • 35

    Osorio JA, Safaee MM, Viner J, Sankaran S, Imershein S, Adigun E, : Cost-effectiveness development for the postoperative care of craniotomy patients: a safe transitions pathway in neurological surgery. Neurosurg Focus 44(5):E19, 2018

    • Search Google Scholar
    • Export Citation
  • 36

    Perneger TV: The Swiss cheese model of safety incidents: are there holes in the metaphor? BMC Health Serv Res 5:71, 2005

  • 37

    Ramaswamy S, Wilson JA, Colvin L: Non-opioid-based adjuvant analgesia in perioperative care. BJA Educ 13:152157, 2013

  • 38

    Ramírez E, Martín A, Villán Y, Lorente M, Ojeda J, Moro M, : Effectiveness and limitations of an incident-reporting system analyzed by local clinical safety leaders in a tertiary hospital: Prospective evaluation through real-time observations of patient safety incidents. Medicine (Baltimore) 97:e12509, 2018

    • Search Google Scholar
    • Export Citation
  • 39

    Rayman G: Virtual glucose management in the hospital setting. Ann Intern Med 166:673674, 2017

  • 40

    Reason J: Understanding adverse events: human factors. Qual Health Care 4:8089, 1995

  • 41

    Reddy SV, Irkal JN, Srinivasamurthy A: Postoperative delirium in elderly citizens and current practice. J Anaesthesiol Clin Pharmacol 33:291299, 2017

    • Search Google Scholar
    • Export Citation
  • 42

    Rolston JD, Han SJ, Lau CY, Berger MS, Parsa AT: Frequency and predictors of complications in neurological surgery: national trends from 2006 to 2011. J Neurosurg 120:736745, 2014

    • Search Google Scholar
    • Export Citation
  • 43

    Schipmann S, Schwake M, Suero Molina E, Roeder N, Steudel WI, Warneke N, : Quality indicators in cranial neurosurgery: which are presently substantiated? A systematic review. World Neurosurg 104:104112, 2017

    • Search Google Scholar
    • Export Citation
  • 44

    Selden NR, Origitano TC, Burchiel KJ, Getch CC, Anderson VC, McCartney S, : A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses. Neurosurgery 70:971981, 2012

    • Search Google Scholar
    • Export Citation
  • 45

    Taylor CL, Ranum D: Patient safety in neurosurgical practice: physician and patient factors that contribute to patient injury. World Neurosurg 93:159163, 2016

    • Search Google Scholar
    • Export Citation
  • 46

    Titsworth WL, Hester J, Correia T, Reed R, Williams M, Guin P, : Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution’s success. J Neurosurg 116:911920, 2012

    • Search Google Scholar
    • Export Citation
  • 47

    Tomov M, Mitsunaga L, Durbin-Johnson B, Nallur D, Roberto R: Reducing surgical site infection in spinal surgery with betadine irrigation and intrawound vancomycin powder. Spine (Phila Pa 1976) 40:491499, 2015

    • Search Google Scholar
    • Export Citation
  • 48

    Valentine EA, Falk SA: Quality improvement in anesthesiology—leveraging data and analytics to optimize outcomes. Anesthesiol Clin 36:3144, 2018

    • Search Google Scholar
    • Export Citation
  • 49

    Wang Y, Liu B, Zhao T, Zhao B, Yu D, Jiang X, : Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial. 130:16801691, 2019

    • Search Google Scholar
    • Export Citation
  • 50

    Wong JM, Bader AM, Laws ER, Popp AJ, Gawande AA: Patterns in neurosurgical adverse events and proposed strategies for reduction. Neurosurg Focus 33(5):E1, 2012

    • Search Google Scholar
    • Export Citation
  • 51

    Yasuhara T, Hishikawa T, Agari T, Kurozumi K, Ichikawa T, Kameda M, : Perioperative management center (PERIO) for neurosurgical patients. Neurol Med Chir (Tokyo) 56:574579, 2016

    • Search Google Scholar
    • Export Citation
  • 52

    Zuckerman SL, France DJ, Green C, Leming-Lee S, Anders S, Mocco J: Surgical debriefing: a reliable roadmap to completing the patient safety cycle. Neurosurg Focus 33(5):E4, 2012

    • Search Google Scholar
    • Export Citation

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