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Incidents and Accidents in Spinal Surgery Takashi Yamazaki 1 1Department of Orthopaedic Surgery,Musashino Red Cross Hospital Keyword: incident report(インシデントレポート) , prevention of accident(事故防止) , spinal surgery(脊椎外科) pp.449-456
Published Date 2005/4/1
DOI https://doi.org/10.11477/mf.1408100089
  • Abstract
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The cause of the accident was investigated in 22 cases of accidents during surgery,10 cases of accidents in diagnosis,and 5 cases of accidents in treatment,including medication or examination errors,extracted from 132 incident reports regarding spinal disorders. The surgical accidents resulted in early death,worsening of palsy,and re-operation,the diagnostic accidents consisted of misdiagnosis,and the treatment accidents resulted in the need for additional treatment. Four of the surgical accidents were unavoidable,7 accidents were over the standard level,and 11 accidents included errors. Eight of the 10 diagnostic accidents included errors. Three of the 5 treatment accidents included errors. It was frequent that 23 cases out of 37 included errors. The accidents did not occur in the difficult condition. The causes of the errors were physicians lack of basic knowledge,carelessness,and negligence. To make spinal surgery safer,it is important to file incident reports,and take measures in human factors or hospital systems.


Copyright © 2005, Igaku-Shoin Ltd. All rights reserved.

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電子版ISSN 1882-1286 印刷版ISSN 0557-0433 医学書院

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