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. 2020 May;90(5):719-724.
doi: 10.1111/ans.15765. Epub 2020 Feb 27.

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

Aashray K Gupta  1   2 , Sasha K Stewart  1 , Kimberley Cottell  1 , Glenn A J McCulloch  1 , John Miller  2 , Wendy J Babidge  2   3 , Guy J Maddern  2   3
Affiliations

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

Aashray K Gupta et al. ANZ J Surg. 2020 May.

Abstract

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.

Keywords: audit; avoidable; delay treatment; mortality; urology.

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References

    1. Beiles CB, Retegan C, Maddern GJ. Victorian Audit of Surgical Mortality is associated with improved clinical outcomes. ANZ J. Surg. 2015; 85: 803-7.
    1. Azzam DG, Neo CA, Itotoh FE, Aitken RJ. The Western Australian Audit of Surgical Mortality: outcomes from the first 10 years. Med. J. Aust. 2013; 199: 539-42.
    1. Kiermeier A, Babidge WJ, McCulloch GAJ, Maddern GJ, Watters DA, Aitken RJ. National surgical mortality audit may be associated with reduced mortality after emergency admission. ANZ J. Surg. 2017; 87: 830-6.
    1. Gupta AK, Stewart SK, Cottell K, McCulloch GA, Babidge W, Maddern GJ. Potentially avoidable issues in neurosurgical mortality cases in Australia: identification and improvements. ANZ J. Surg. 2017; 87: 86-91.
    1. Chan JCY, Gupta AK, Stewart SK et al. Mortality in Australian cardiothoracic surgery: findings from a national audit. Ann. Thorac. Surg. 2019. https://doi.org/10.1016/j.athoracsur.2019.09.060.

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