title: Potentially avoidable issues in neurosurgical mortality cases in Australia: identification and improvements.
abstract: BACKGROUND
  Mortality rates are commonly used to evaluate the quality of surgical care; however, a large proportion of surgical deaths are unavoidable. Examination of the potentially avoidable issues in surgical deaths can provide a strong basis for quality improvement. Using data from a well-established and comprehensive national surgical mortality audit, we sought to identify the most common avoidable factors in neurosurgical deaths, focusing on the lessons that can be learnt.
  
  
  METHODS
  This study analysed data from a peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2014, focusing on neurosurgery cases with identified areas for improvement in patient management. In the 6% of neurosurgical cases that had clinical incidents, there were 193 clinical events identified. These were first categorized based on the perioperative stage (pre-, intra- or postoperative) followed by thematic analysis within each stage.
  
  
  RESULTS
  The study found preoperative issues to be the most common (n = 107) followed by postoperative issues (n = 31) and intraoperative issues (n = 29). The most common theme was inadequate assessment (n = 65) followed by poor communication (at any stage of treatment) (n = 26).
  
  
  CONCLUSIONS
  Neurosurgical cases with potentially avoidable mortality constitute a small but important subset. Avoidable contributors to mortality occurred most frequently at the preoperative stage, most commonly relating to inadequate assessment and delays. These findings can inform various stakeholders to improve the quality and safety of surgical care.
authors.affiliation: South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.
authors.forename: Aashray K
authors.initials: AK
authors.lastname: Gupta
authors.affiliation: South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.
authors.forename: Sasha K
authors.initials: SK
authors.lastname: Stewart
authors.affiliation: South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.
authors.forename: Kimberley
authors.initials: K
authors.lastname: Cottell
authors.affiliation: South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.
authors.forename: Glenn A J
authors.initials: GA
authors.lastname: McCulloch
authors.affiliation: University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.|Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.
authors.forename: Wendy
authors.initials: W
authors.lastname: Babidge
authors.affiliation: University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.|Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.
authors.forename: Guy J
authors.initials: GJ
authors.lastname: Maddern
mesh_terms: D001315:Australia / Q000453:epidemiology; D006801:Humans; D008485:Medical Audit; D019635:Neurosurgical Procedures / Q000401:mortality*; D010380:Peer Review / Q000379:methods*; D058996:Quality Improvement; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends
keywords: audit; avoidable; delay treatment; mortality; neurosurgery