title: Analysis of Incident and Accident Reports and Risk Management in Spine Surgery.
abstract: METHODS
  A review of accident and incident reports.
  
  
  OBJECTIVE
  To analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery.
  
  
  BACKGROUND
  In our institution, a clinical error that potentially results in an adverse event is usually submitted as an incident or accident report through a web database, to ensure anonymous and blame-free reporting. All reports are analyzed by a medical safety management group. These reports contain valuable data for management of medical safety, but there have been no studies evaluating such data for spine surgery.
  
  
  METHODS
  A total of 320 incidents and accidents that occurred perioperatively in 172 of 415 spine surgeries were included in the study. Incidents were defined as events that were "problematic, but with no damage to the patient," and accidents as events "with damage to the patient." The details of these events were analyzed.
  
  
  RESULTS
  There were 278 incidents in 137 surgeries and 42 accidents in 35 surgeries, giving prevalence of 33% (137/415) and 8% (35/415), respectively. The proportion of accidents among all events was significantly higher for doctors than non-doctors [68.0% (17/25) vs. 8.5% (25/295), P < 0.01] and in the operating room compared with outside the operating room [40.5% (15/37) vs. 9.5% (27/283), P < 0.01]. There was no significant difference in years of experience among personnel involved in all events. The major types of events were medication-related, line and tube problems, and falls and slips. Accidents also occurred because of a long-term prone position, with complications such as laryngeal edema, ulnar nerve palsy, and tooth damage.
  
  
  CONCLUSIONS
  Surgery and procedures in the operating room always have a risk of complications. Therefore, a particular effort is needed to establish safe management of this environment and to provide advice on risk to the doctor and medical care team.
  
  
  METHODS
  4.
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Kazuyoshi
authors.initials: K
authors.lastname: Kobayashi
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Shiro
authors.initials: S
authors.lastname: Imagama
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Kei
authors.initials: K
authors.lastname: Ando
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Tetsuro
authors.initials: T
authors.lastname: Hida
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Kenyu
authors.initials: K
authors.lastname: Ito
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Mikito
authors.initials: M
authors.lastname: Tsushima
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Yoshimoto
authors.initials: Y
authors.lastname: Ishikawa
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Akiyuki
authors.initials: A
authors.lastname: Matsumoto
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Masayoshi
authors.initials: M
authors.lastname: Morozumi
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Nishida
authors.affiliation: Department of Quality and Patient Safety, Nagoya University Hospital, Aichi, Nagoya, Japan.
authors.forename: Yoshimasa
authors.initials: Y
authors.lastname: Nagao
authors.affiliation: Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Nagoya, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Ishiguro
mesh_terms: D000059:Accidents / Q000706:statistics & numerical data / Q000639:trends; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data / Q000639:trends*; D008875:Middle Aged; D009873:Operating Rooms / Q000592:standards / Q000639:trends; D012308:Risk Management / Q000706:statistics & numerical data / Q000639:trends*; D017751:Safety Management / Q000706:statistics & numerical data / Q000639:trends*; D013122:Spinal Diseases / Q000453:epidemiology / Q000601:surgery*; D014342:Truth Disclosure