Lessons learned from national surgical audits

Unexpected deaths after endocrine surgery: learning from rare events using a national audit of surgical mortality

BACKGROUND

The mortality rate is low in endocrine surgery, making it a difficult outcome to use for quality improvement in individual units. Lessons from population data sets are of value in improving outcomes. Data from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) were used here to understand and elucidate potential systems issues that may contribute to preventable deaths.

METHODS

ANZASM data relating to 30-day mortality after thyroidectomy, parathyroidectomy, and adrenalectomy from 2009 to 2020 were reviewed. Mortality rates were calculated using billing data. Thematic analysis of independent assessor reports was conducted to produce a coding framework.

RESULTS

A total of 67 deaths were reported, with an estimated mortality rate of 0.03-0.07 per cent (38 for thyroidectomy (0.03-0.06 per cent), 16 for parathyroidectomy (0.03-0.06 per cent), 13 for adrenalectomy (0.15-0.33 per cent)). Twenty-seven deaths (40 per cent) were precipitated by clinically significant adverse events, and 18 (27 per cent) were judged to be preventable by independent ANZASM assessors. Recurrent themes included inadequate preoperative assessment, lack of anticipation of intraoperative pitfalls, and failure to recognize and effectively address postoperative complications. Several novel themes were reiterated, such as occult ischaemic heart disease associated with death after parathyroid surgery, unexpected intraoperative difficulties from adrenal metastasis, and complications due to anticoagulation therapy after thyroid surgery.

CONCLUSION

This study represents a large-scale national report of deaths after endocrine surgery and provides insights into these rare events. Although the overall mortality rate is low, 27 per cent of deaths involved systems issues that were preventable following independent peer review.

Potentially avoidable issues in urology mortality cases in Australia: identification and improvements

BACKGROUND

This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt.

METHODS

This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage.

RESULTS

The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant.

CONCLUSION

Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care.

"Nobody told me": Communication Issues Affecting Australian Cardiothoracic Surgery Patients

BACKGROUND

Failure of communication can have potentially severe results in cardiothoracic surgery. Previous literature regarding patient safety highlighted communication as a common area for improvement. This study utilized a qualitative approach to analyze a national mortality audit data set to identify and describe communication issues that could potentially contribute to patient mortality following cardiothoracic surgery.

METHODS

We utilized a peer-reviewed audit of surgical deaths after cardiothoracic surgery in Australian hospitals from 2009 to 2015 via the Australian and New Zealand Audit of Surgical Mortality. Cases were identified with clinical management issues then individual analysis of cases highlighting communication issues was undertaken. A total of 91 reports from surgeons and assessors were analysed using a thematic analytic approach.

RESULTS

A total of 908 cases of potentially avoidable mortality were identified as being associated with clinical management issues, and communication issues were identified in 91 (10%) of these cases, which served as the basis for this analysis. The study found that failure to achieve shared decision making was the most common theme (n = 38, 41.8%), followed by failure to notify patient deterioration (n = 22, 24.1%), misreporting of patient condition (n = 10, 11.0%) and issues related to informed consent (n = 9, 10.0%). The most frequent communication issues occurred between surgeons and the intensive care unit.

CONCLUSIONS

Poor communication was identified in patients who died after cardiothoracic surgery. Communication is an important modifiable factor in patient mortality. Efforts to address teamwork and communication have the potential to improve safety and quality of care for patients undergoing cardiothoracic surgery.

Research considerations in the evaluation of minimally invasive pancreatic resection (MIPR)

The IHPBA/AHPBA-sponsored 2016 minimally invasive pancreatic resection (MIPR) conference held on April 20th, 2016 included a session designed to evaluate what would be the most appropriate scientific contribution to help define the increasing role of MIPR internationally. Participants in the conference reviewed the assessment of numerous pertinent scientific designs including randomized controlled trial (RCT), pragmatic international RCT, registry-RCT, non-RCT with propensity matching, and various types of clinical registries including those aiming to create a quality improvement data system or a learning health care system. The strengths and weaknesses of each of these designs, the status of trials which are currently recruiting patients, and pragmatic considerations were evaluated. A recommendation was made to establish a clinical registry to collect data prospectively from around the world to assess current practices and provide a framework for future studies in MIPR.