• Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Tetsuro Hida, Kenyu Ito, Mikito Tsushima, Yoshimoto Ishikawa, Akiyuki Matsumoto, Masayoshi Morozumi, Yoshihiro Nishida, Yoshimasa Nagao, and Naoki Ishiguro.
• *Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya 466-8550; Japan †Department of Quality and Patient Safety, Nagoya University Hospital, 65 Tsurumai Showa-ward, Aichi, Nagoya 466-8550; Japan.
• Spine. 2017 Jan 16.

Study DesignA review of accident and incident reports.ObjectiveTo analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery.Summary Of Background DataIn 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 these kind of data for spine surgery.MethodsA 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.ResultsThere were 278 incidents in 137 surgeries and 42 accidents in 35 surgeries, giving prevalences 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 to 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 due to a long-term prone position, with complications such as laryngeal edema, ulnar nerve palsy, and tooth damage.ConclusionSurgery 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.Level Of Evidence4.

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