A Complication Conference for Internal Quality Control at the Neurosurgical Department of the University of Heidelberg
The registration of adverse events is an important issue in the field of medicine. Even today adverse event screening and registration is not part of the routine in most medical areas. In 1994, the Department of Neurosurgery at the University of Heidelber
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A Complication Conference for Internal Quality Control at the Neurosurgical Department of the University of Heidelberg M. M. Bonsanto, J. Hamer, V. Tronnier, and S. Kunze Department of Neurosurgery, University of Heidelberg, Germany
Summary The registration of adverse events is an important issue in the field of medicine. Even today adverse event screening and registration is not part of the routine in most medical areas. In 1994, the Department of Neurosurgery at the University of Heidelberg implemented a conference for screening and registering adverse events. The aim was to record all complications occurring for an internal quality control. High priority was given to improving the process of data screening and registering. The conference is held every 2 weeks and all medical staff and residents of the department are obligated to be present. Screening of the adverse events encompasses all operations performed during a bi-weekly period. Every single operation is revised for an adverse event during or following the hospital stay. Adverse events are registered on a standardized data sheet and later transferred to a database for use in further investigations. After 6 years, the conference has been fully accepted and become an integral part of the workflow of the department. During this period, SI60 operations were screened and 1335 adverse events registered. The next step will be to integrate the data-collection process into the daily ward rounds using a personal digital assistant (PDA). This process is less time consuming and may perhaps augment the number of registered cases. Keywords: Adverse events; complications conference; data screening and registration; internal quality control.
Introduction The registration of adverse events occurring during neurosurgical operations is still not a standard procedure in most neurosurgical departments today. In the US and the UK, morbidity and mortality conferences (M&M conference) are part of an internal quality control process in surgical departments, but such conferences rather serve as a forum for analyzing and discussing particular adverse events which then in turn can be used as a powerful teaching tool [2, 3, 12-14, 21,24, 29]. Only few M&M conferences are used for screening adverse events. However, the screening and registration of adverse events as part of an M&M conference could offer additional benefits than the
mere teaching effect. If all adverse events that occur are screened frequently, reliable data can be obtained regarding the actual number of complications. Such data could then form the basis for a further systematic error analysis, with the goal of increased patient safety and quality improvement [1,7,9,10,15,22,23,25,27, 28, 31, 33]. The time consuming aspect of the data collection process, different views and definition of what is considered an adverse event, and the possibility to use the M&M conference as a platform to blame single persons, makes it difficult to implement such conferences for the approach of a systematic error screening in every medic
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