Complications are an inherent part of our practice of medicine, especially with surgical specialities. Neurosurgery is the most intricate of all, and complications in this field can be truly devastating, and may not only make the patient and his/her family miserable but also tarnish the name of the neurosurgeon and the specialty at large. There are two sides of the coin of Complications – Anticipation or Prevention, and Recognition and Management. In our increasingly litigious society, it is best to make every effort to prevent them from occurring by careful attention to patient’s history and clinical examination (before jumping to the images), accurate reading of scans and other investigations, and discussing the nuances of the case, preparing detailed plan and alternatives towards its approach, execution and closure (or repair), with members of the neurosurgical and allied specialty teams. Involving the patient and his/her family in decision-making, making them allies of our plan and patient-care will lessen the ill-feeling and agitation that can possibly arise following a complication. Intra-op management of complication is often complex, and if well-planned, intra-op adverse events can be handled swiftly, and with least fuss or agony between the surgeon and his team; but in the face of unexpected events, much will depend upon the experience and wisdom of the surgeon. Again, it is necessary and prudent to convey such events to the patient’s family as soon as one can.
The issue of dealing with Complications in Neurosurgery is vast, and opinions diverse and even paradoxical. Social, cultural, geographical and economic factors also come into play. Hence, it is essential to discuss such cases and events in an open forum, unabashedly, with a view to learning from each other, and as an obligation to our patients. Such a forum can help us share and lighten the huge burden we carry, create consensus and even act as insulation from criticism or penal action by the authorities.
With this, and many such issues in mind, we had organised the 1st International Conference on Complications in Neurosurgery (ICCN) in Mumbai, India in March, 2017. This was attended by 383 delegates from 25 countries. All 215 presentations were deliberated over 3 days (average 72/day) in one ballroom hall so that no one missed out any discussion. The response at that meeting and its spinoffs were truly encouraging. Suddenly there is a buzz all around with many local and regional conferences devoting a session or two to discussing Complications, with some basing the theme of an entire conference on it. The President of WFNS pronounced a new Committee on this important issue under my Chairmanship, and we are now poised to host the 2nd ICCN, again in Mumbai, 25th thru 27th January, 2019.
Whilst the basic format remains the same as of 1st ICCN, we will minimise didactic lectures and provide more time for discussion. The details of scientific program will be spelt out in the appropriate section. We invite all members of our large neurosurgical community from all corners of the world to meet under one roof and partake of this unique educational event.
Congratulations to you on the organization of the 2nd International Conference on Complications in Neurosurgery. As Neurosurgeons, it is most important that we remember our challenging cases, and complications that may arise. We all will have our complications as neurosurgeons throughout the world. The important point is how we manage these complications. Typically, it is the review and analysis of our complications which lead to tremendous improvement in our specialty.
For all these reasons, it is critically important that meetings such as 2nd ICCN continue to be held. I am sorry I cannot be with you at this time. However, I wish you all the success possible in your meeting, and I look forward to reading about its proceedings in due course.
With best wishes,
OC, O Ont, MD, PhD, FRCSC
It is already time for the Second International Conference on Complications in Neurosurgery. The first conference was successful, ant the occurrence of these conferences mark a breakthrough in Neurosurgery. Hitherto, complications have been an elephant in the room which have been accomplished to occur in the hands of “others” and I hospitals such as “St Elswhere”.
This means that neurosurgical careers have been forged in denial of untoward outcomes and complications; it has been common to view complications as signs of insufficient professional abilities and subsequently difficult to admit and handle personal complications. Naturally, insufficient knowledge and deficient professional ethics can lie behind complications and neglect of complications can reflect disregard for patients’ wellbeing: one can read papers where surgeons review their own retrospective series, and evaluate considerable morbidity and mortality as “acceptable”.Click here to continue reading
The transparent compilation and handling of complications entails two very important aspects.
One relates to the patients’ perspective: It is probably not the responsible surgeon who alone should evaluate whether an outcome or complication is acceptable. The patient and responsible surgeon should agree on the expected outcomes and risks – and evaluate whether they are “acceptable” within this frame of reference.
The second aspect is even more important. Philosophically, the unexpected is always a possibility, unless one has perfect knowledge of how the universe works. Science aims to describe theories to explain the causality of events, but the theories can only be viewed as approximations of reality; approximations that need to be adjusted when prognoses based on commonly accepted knowledge fail to predict the future. The philosopher coined the term “black swans” to describe unexpected events or observations that falsified an accepted belief. Unfortunately, such events can occur even if we, as surgeons and scientists, act conscientiously within accepted theoretical paradigms and we honest intent to help our patients. In this event, a complication is something that shows that our action was based on incomplete or faulty knowledge. Naturally, dissemination of such observations of “black swans” can only benefit our specialty. The discordant data require better theories and practice and the knowledge of a possible untoward event will serve as a warning to others not to repeat a mistake.
The handling of complications is one of the most important issues in our professionalism. We need to provide our services in dialogue with our patients and we need to exert professional ethics and self-regulation to prevent complications that arise from professional negligence or ignorance. We also need to exert professionalism to learn from the complications that are “black swans” and to prepare collegially to handle the unexpected.
I am convinced that transparency with our practice and outcomes will be an important future means of improving professional performance and knowledge. I salute the congress, the participants and organizers and wish you success in the important endeavor of professional perfection.
Editor in chief, Acta Neurochirurgica
INITIAL TRAINING IN NEUROSURGERY AND RISK MANAGEMENT
The training of a surgeon should no longer be limited to the theoretical and practical teaching of the treatment of diseases of the specialty, with the main focus being the surgical procedure (1). Taking into account the quality and safety of care is imperative. In addition to the decision-making capacity, the information given to patients as well as the risk management must be a new priority and must be integrated into the initial training.
The worldwide literature (1) on patient safety reveals the importance of medical risks in hospital structures with 350 000 to 460 000 serious events per year in France, of which 120 000 to 190 000 can be considered as available (2). Data on 1,777,035 patients for the years 2006-2011 were acquired from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Neurosurgical cases were extracted by querying the data for which the surgical specialty was listed as "neurological surgery." Over 38,000 neurosurgical cases were analyzed, with complications occurring in 14.3% (3)Click here to continue reading
The human factor frequently appears as an immediate cause of adverse events (4). Prior to 1990, the cultural approach in risk management was geared towards finding the responsibilities of the authors of errors. From 1990, J. Reason (4) develops a new approach to the risk by considering that human error is inevitable but "Although we can not change the human condition, we can change the conditions in which humans work ... Human errors are perceived as consequences rather than causes. "
Human errors develop in a context (root causes) favoring their occurrence. L. Leape (5) states that "Human error is not avoidable but it is relatively predictable. If the magnitude of the medical error is enormous, it is because of the use of poorly designed systems and not the irresponsibility of staff. " D. Berwick (6) reinforces this systemic approach to risk by demonstrating that only 2-3% of clinical errors are due to incompetence, carelessness, sabotage or negligence, revealing that 97-98% of clinical errors are due to the health system hazards.
Recognized protocols are used in care systems to investigate and analyze incidents (Clinical Safety Research Unit (Imperial College London), Association of Litigation and Risk Management (ALARM), from the identification of the causes of an event (7,8) The Human Factors Analysis and Classification System (HFACS) was originally proposed for US Navy aviation and then modified to apply to a wide variety of other risks, including those related to care, to study and analyze the human contribution to accidents and incidents. It takes into account individual, environmental, governance and organizational factors. For example: action or omission in the care process, slip of the tongue, misjudgment, forgetfulness, unsafe gesture, improper or incomplete implementation of a procedure, deliberate failure to practice safe practices, procedures or standards, search for root causes, contributing factors to the occurrence of these errors to correct them by installing defenses or barriers, to create a safer environment. In this context, at the individual level, the most frequent contributions were errors in judgment, inadequate risk assessment or lack of critical reflection. Communication and coordination, mainly due to inadequate or ineffective communication, have been often implicated. Half of the reports have blamed complex interactions in a sociotechnical environment. These methodologies are useful. Exploited carefully, they must guide our mitigation and response strategies better than simple assumptions and opinions.
The meeting in Bombay is the opportunity to create a database that could be used in the neurosurgical career development by creating a specific training module for managing risks and complications.
This teaching that we should organized must be focused to the practical implementation and the study of scenarios, thanks to workshops in small groups, exercises in simulation based on real scenarios. To create this bank of scenarios close to the field, teams of experts must be involved: neuro-traumatology, cerebrovascular, tumors, spine, functional neurosurgery, neuropediatrics, peripheral nerves, ... A syllabus of skills - knowledge, know-how and skills - taking into account the aspect of the mastery of illness is essential, but a critical analysis of the environment will optimize access to neurosurgical clinical performance.
The change of practice and culture goes through initial training.
1- Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Institute of Medicine. Washington (DC) 1999.
2- DRESS ; Les événements indésirables graves liés aux soins observés dans les établissements de santé : premiers résultats d’une étude nationale. https://drees.solidarites-sante.gouv.fr/IMG/pdf/er398-3.pdf
3- Rolston JD, Han SJ, Lau CY, Berger MS, Parsa AT: Frequency and predictors of complications in neurological surgery: National trends from 2006 to 2011. J Neurosurg 2014; 120:736–45
4- Reason J. “Human error: models and management”, BMJ, vol. 320, n° 7237, 18 mars 2000, p. 768-770.
5- Dr Lucien Leape https://www.npsf.org/page/lucianleapemd
6- Berwick DM. The Institute for Healthcare Improvement. Committee on Senate Appropriations Subcommittee of Labor, Health and Human Services, March 13, 2003
7- Vincent C. Systems analysis of clinical incidents – The London Protocol https://www.imperial.ac.uk/patient-safety-translational-research-centre/education/training-materials-for-use-in-research-and-clinical-practice/the-london-protocol/
8- Vincent C. How to investigate and analyse clinical incidents. BMJ 2000;320:777-781
MD, MSc Health Economy, Professor of Neurosurgery
Expert, High Authority of Health (Paris), Education Committee, World Federation of Neurosurgical Societies
My Dear Keki
Thank you for the superb and unique meeting you organized in Mumbai. Your choice was fabulous since we rarely spend sufficient time on complications and errors in our practice. I enjoy the discussions and controversies concerning special cases especially because the majority of speaker play an honest role talking on what they have have done wrongly and what they were supposed to do.
Thank you for that and thank you for the incredible organization of your meeting. The social program was great and I was impressed by the show and the female singer.
Kind regards my dear friend for your kind invitation.
Before leaving India, I would like to thank you - formally - again very much for your great thoughts and efforts with which you and your team made this fascinating congress possible. I learned a lot from all lectures and the discussions, and it would be great pleasure for me if we would edit a possible book together, if you wish.
All the best - relax and enjoy - and do keep a good work-life balance!
Dear Prof. Keki Turel,
Thank you for inviting me to this wonderful conference. And congratulations on your success. The content was so educational as to greatly impress myself. I will continue to brush up my skills while truthfully taking care of the patient.
Looking forward to seeing you next.
Thank you very much for everything in Mumbai.
Your congress was so wonderful, and very philosophical.
I could study a lot.
I hope to see you again. Thank you very much.
It was a wonderful meeting which I never experienced before. Complication is the mother of improvement of skill and knowledges. This kind meet will greatly impact YNS and senior NS both.
Once again thank you for your hospitality and give us a chance.
Dear Dr Keki
Thank you very much for your hospitality.
The meeting was so impressive for me discussing about complications. Your passion and will, led us to such a successful meeting.
I could not meet you for saying my appreciation and good-bye at the final day.
Thank you very much.
Thank you very much.
My hat-off salute to you and your team on successful completion of such an extraordinary meeting on Neurosurgery.
I feel proud to be part of the meet.
Dear Dr Turel,
Thanks for the opportunity to present at the meeting. It is truly a unique event. I learnt a lot in the time I was there.
Hope you conduct this annually.
Heartiest congratulations for organizing a successful conferece... It was throughly enjoying, educational and has provided room for more thought and introspection.
Thank you for providing an opportunity to reflect within and participate in the scientific proceedings.
I am great full for your kind invitation and hospitality. I appreciate your kind thought of providing me a platform in your esteemed workshhop.
"One complication leads to another - The Domino Effect. It may often not be the last."