Towards standardized measurement of adverse events in spine surgery: Conceptual model and pilot evaluation

BMC Musculoskeletal Disorders

Volumn 7, Issue , 2006, Pages

  Mirza, Sohail K ^a,b   Deyo, Richard A ^a   Heagerty, Patrick J ^a   Turner, Judith A ^b   Lee, Lorri A ^a   Goodkin, Robert ^b  

^a UNIVERSITY OF WASHINGTON   (United States)

^b UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; COMORBIDITY; CONTROLLED STUDY; HUMAN; LUMBAR SPINE; MEDICAL RECORD; POSTOPERATIVE COMPLICATION; SPINE SURGERY; SURGICAL TECHNIQUE;

HUMANS; LUMBAR VERTEBRAE; MULTIVARIATE ANALYSIS; OUTCOME ASSESSMENT (HEALTH CARE); PILOT PROJECTS; POSTOPERATIVE COMPLICATIONS; PROSPECTIVE STUDIES; SPINAL DISEASES; SURGICAL PROCEDURES, OPERATIVE; TERMINOLOGY AS TOPIC;

EID: 33748514562     PISSN: 14712474     EISSN: 14712474     Source Type: Journal    
DOI: 10.1186/1471-2474-7-53     Document Type: Article

References (64)

1. Robert G, Stevens A, Gabbay J: 'Early warning systems' for identifying new healthcare technologies. Health Technol Assess 1999, 3(13):1-108.
2. Boden SD, Balderston RA, Heller JG, Hanley ENJ, Zigler JE: An AOA critical issue. Disc replacements: this time will we really cure 0low-back and neck pain? J Bone Joint Surg Am 2004, 86-A(2):411-422.
3. Callaghan JJ, Crowninshield RD, Greenwald AS, Lieberman JR, Rosenberg AG, Lewallen DG: Symposium: introducing technology into orthopaedic practice. How should it be done? J Bone Joint Surg Am 2005, 87(5):1146-1158.
4. Weiss NS: Clinical Epidemiology: the study of the outcome of illness. Second Edition edition. New York , Oxford University Press; 1996.
5. Hunter D: First, gather the data. N Engl J Med 2006, 354(4):329-331.
6. Chang A, Schyve PM, Croteau RJ, O'Leary DS, Loeb JM: The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care 2005, 17(2):95-105.
7. Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G, Gibbs J, Grover F, et al.: The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 1995, 180(5):519-31.
8. Prabhakar G, Haan CK, Peterson ED, Coombs LP, Cruzzavala JL, Murray GF: The risks of moderate and extreme obesity for coronary artery bypass grafting outcomes: a study from the Society of Thoracic Surgeons' database. Ann Thorac Surg 2002, 74(4):1125-30; discussion 1130-1.
9. Vogt MT, Hanscom B, Lauerman WC, Kang JD: Influence of smoking on the health status of spinal patients: the National Spine Network database. Spine 2002, 27(3):313-319.
10. Weeks WB, Bazos DA, Bott DM, Lombardo R, Racz MJ, Hannan EL, Fisher ES: New York's statistical model accurately predicts mortality risk for veterans who obtain private sector CABG. Health Serv Res 2005, 40(4):1186-1196.
11. Bridges CR, Edwards FH, Peterson ED, Coombs LP: The effect of race on coronary bypass operative morality. J Am Coll Cardiol 2000, 36:1870-1876.
12. Vogt MT, Rubin DA, Palermo L, Christianson L, Kang JD, Nevitt MC, Cauley JA: Lumbar spine listhesis in older African American women. Spine J 2003, 3(4):255-261.
13. Gatchel RJ, Polatin PB, Mayer TG: The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine 1995, 20(24):2702-2709.
14. El Masry WS, Tsubo M, Katoh S, El Miligui YH, Khan A: Validation of the American Spinal Injury Association (ASIA) motor score and the National Acute Spinal Cord Injury Study (NASCIS) motor score. Spine 1996, 21(5):614-619.
15. Elfering A, Semmer N, Birkhofer D, Zanetti M, Hodler J, Boos N: Risk factors for lumbar disc degeneration: a 5-year prospective MRI study in asymptomatic individuals. Spine 2002, 27(2):125-134.
16. Dora C, Walchli B, Elfering A, Gal I, Weishaupt D, Boos N: The significance of spinal canal dimensions in discriminating symptomatic from asymptomatic disc herniations. Eur Spine J 2002, 11(6):575-581.
17. Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA: Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine 2005, 30(13):1541-8; discussion 1549.
18. Perennou D, Marcelli C, Herisson C, Simon L: Adult lumbar scoliosis. Epidemiologic aspects in a low-back pain population. Spine 1994, 19(2):123-128.
19. Vialle R, Levassor N, Rillardon L, Templier A, Skalli W, Guigui P: Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. J Bone Joint Surg Am 2005, 87(2):260-267.
20. NCCMERP: NCC MERP Index for Categorizing Medication Errors Algorithm. [http://www.nccmerp.org/pdf/algorColor2001-06-12.pdf].
21. Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE: The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine 1996, 21(15):1787-94; discussion 1794-5.
22. Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE: The Maine Lumbar Spine Study, Part II: 1-year outcomes of surgical and nonsurgical management of sciatica. Spine 1996, 21(15):1777-1786.
23. Keller RB, Atlas SJ, Singer DE, Chapin AM, Mooney NA, Patrick DL, Deyo RA: The Maine Lumbar Spine Study, Part I. Background and concepts. Spine 1996, 21(15):1769-1776.
24. McHorney CA, Kosinski M, Ware JE: Comparisons of the costs and quality of norms for the SF-36 health survey collected by mail versus telephone interview: Results from a national survey. Medical Care 1994, 32:551-567.
25. McHorney CA, Ware JE, Raczek AE: The MOS 36-item short-form health survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care 1993, 31:247-263.
26. Ware JJ, Sherbourne CD: The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care 1992, 30:473-483.
27. Wiggins GC, Mirza S, Bellabarba C, West GA, Chapman JR, Shaffrey CI: Perioperative complications with costotransversectomy and anterior approaches to thoracic and thoracolumbar tumors. In Neurosurgical Focus Volume 11(6). American Association of Neurological Surgeons; 2001:1-9.
28. Reilly DF, McNeely MJ, Doerner D, Greenberg DL, Staiger TO, Geist MJ, Vedovatti PA, Coffey JE, et al.: Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med 1999, 159(18):2185-2192.
29. Posner KL, Freund PR: Trends in quality of anesthesia care associated with changing staffing patterns, productivity, and concurrency of case supervision in a teaching hospital. Anesthesiology 1999, 91(3):839-847.
30. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, Siegler M: An alternative strategy for studying adverse events in medical care. Lancet 1997, 349(9048):309-313.
31. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991, 324(6):370-376.
32. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H: The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991, 324(6):377-384.
33. JCAHO: Sentinel Event Policy and Procedures, Updated June 2005. [http://www.jointcommission.org/SentinalEvents/PolicyandProcedures/].
34. NCCMERP: NCC MERP Index for Categorizing Medication Errors. [http://www.nccmerp.org/pdf/indexColor2001-06-12.pdf].
35. Katz JN, Chang LC, Sangha O, Fossel AH, Bates DW: Can comorbidity be measured by questionnaire rather than medical record review? Med Care 1996, 34(1):73-84.
36. Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987, 40(5):373-383.
37. Sangha O, Stucki G, Liang MH, Fossel AH, Katz JN: The Self-Administered Comorbidity Questionnaire: a new method to assess comorbidity for clinical and health services research. Arthritis Rheum 2003, 49(2):156-163.
38. Elixhauser A, Steiner C, Harris DR, Coffey RM: Comorbidity measures for use with administrative data. Med Care 1998, 36(1):8-27.
39. Leung JM, Dzankic S: Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc 2001, 49(8):1080-1085.
40. Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N: Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine 2001, 26(17):1873-1878.
41. Pye SR, Reid DM, Smith R, Adams JE, Nelson K, Silman AJ, O'Neill TW: Radiographic features of lumbar disc degeneration and self-reported back pain. J Rheumatol 2004, 31(4):753-758.
42. O'Neill TW, McCloskey EV, Kanis JA, Bhalla AK, Reeve J, Reid DM, Todd C, Woolf AD, Silman AJ: The distribution, determinants, and clinical correlates of vertebral osteophytosis: a population based survey. J Rheumatol 1999, 26(4):842-848.
43. Benneker LM, Heini PF, Anderson SE, Alini M, Ito K: Correlation of radiographic and MRI parameters to morphological and biochemical assessment of intervertebral disc degeneration. Eur Spine J 2005, 14(1):27-35.
44. Fardon DF, Milette PC: Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine 2001, 26(5):E93-E113.
45. Speciale AC, Pietrobon R, Urban CW, Richardson WJ, Helms CA, Major N, Enterline D, Hey L, Haglund M, Turner DA: Observer variability in assessing lumbar spinal stenosis severity on magnetic resonance imaging and its relation to cross-sectional spinal canal area. Spine 2002, 27(10):1082-1086.
46. Timon SJ, Gardner MJ, Wanich T, Poynton A, Pigeon R, Widmann RF, Rawlins BA, Burke SW: Not all spondylolisthesis grading instruments are reliable. Clin Orthop Relat Res 2005:157-162.
47. Capasso G, Maffulli N, Testa V: Inter- and intratester reliability of radiographic measurements of spondylolisthesis. Acta Orthop Belg 1992, 58(2):188-192.
48. Wood KB, Popp CA, Transfeldt EE, Geissele AE: Radiographic evaluation of instability in spondylolisthesis. Spine 1994, 19(15):1697-1703.
49. McGregor AH, Cattermole HR, Hughes SP: Global spinal motion in subjects with lumbar spondylolysis and spondylolisthesis: does the grade or type of slip affect global spinal motion? Spine 2001, 26(3):282-286.
50. Schwab F, el-Fegoun AB, Gamez L, Goodman H, Farcy JP: A lumbar classification of scoliosis in the adult patient: preliminary approach. Spine 2005, 30(14):1670-1673.
51. Schwab FJ, Smith VA, Biserni M, Gamez L, Farcy JP, Pagala M: Adult scoliosis: a quantitative radiographic and clinical analysis. Spine 2002, 27(4):387-392.
52. Jackson RP, Peterson MD, McManus AC, Hales C: Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients. Spine 1998, 23(16):1750-1767.
53. Landis JR, Koch GG: An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics 1977, 33(2):363-374.
54. Landis JR, Koch GG: The measurement of observer agreement for categorical data. Biometrics 1977, 33(1):159-174.
55. Maclure M, Willett WC: Misinterpretation and misuse of the kappa statistic. Am J Epidemiol 1987, 126(2):161-169.
56. Steinley D, Wood P: ICC.sas - a program to calculate Intra-Class Correlations and Confidence Intervals. Accessed at http://www.missouri.edu/ ~umcasadorg/occasional_papers_series.htm on December 2, 2005. University of Missouri-Columbia ; 2000.
57. Berlinger N, Wu AW: Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error. J Med Ethics 2005, 31(2):106-108.
58. Wu AW: Medical error: the second victim. The doctor who makes the mistake needs help too. Bmj 2000, 320(7237):726-727.
59. Krizek TJ: Surgical error: reflections on adverse events. Bull Am Coll Surg 2000, 85(7):18-22.
60. Krizek TJ: Surgical error: ethical issues of adverse events. Arch Surg 2000, 135(11):1359-1366.
61. Risucci DA, Sullivan T, DiRusso S, Savino JA: Assessing educational validity of the Morbidity and Mortality conference: a pilot study. Curr Surg 2003, 60(2):204-209.
62. Harbison SP, Regehr G: Faculty and resident opinions regarding the role of morbidity and mortality conference. Am J Surg 1999, 177(2):136-139.
63. Pierluissi E, Fischer MA, Campbell AR, Landefeld CS: Discussion of medical errors in morbidity and mortality conferences. Jama 2003, 290(21):2838-2842.
64. Ricci M, Goldman AP, de Leval MR, Cohen GA, Devaney F, Carthey J: Pitfalls of adverse event reporting in paediatric cardiac intensive care. Arch Dis Child 2004, 89(9):856-859.