2. Potentially avoidable issues in Surgical mortality: Findings of a national audit
Aashray K. Gupta1, Sasha K. Stewart1, Kimberley Cottell1, Glenn A. J. McCulloch1, John Miller2, Ray Li1, Robert A. Fitridge2, Wendy Babidge2,3, Guy J Maddern2,3
1 South Australian Audit of Perioperative Mortality (SAAPM), Royal Australasian College of Surgeons
2 University of Adelaide Discipline of Surgery
3 Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons

3. BACKGROUND Mortality rates are commonly used to evaluate surgical care
Large proportion of deaths are unavoidable
Potentially avoidable issues in surgical deaths
Quality improvement
Data from the RACS national mortality audit (ANZASM)

4. AIM
To identify the most common potentially avoidable factors in surgical deaths
Neurosurgery1
Urology
Vascular Surgery
Focus on lessons that can be learnt
1 Gupta AK, Stewart SK, Cottell K, McCulloch GAJ, Babidge W, Maddern GJ. Potentially avoidable issues in neurosurgical mortality cases in Australia: identification and improvements. ANZ Journal of Surgery (2017); 87(1-2):

5. METHODOLOGY ANZASM database All hospitals
Independent peer-review process
Partial blinding
Qualitative, thematic analysis
Braun & Clarke, 2006
Two independent researchers

6. METHODOLOGY Categories of clinical incident (ANZASM)
Area of consideration
Area of concern
Adverse event
Only areas of concern and adverse events were analysed
Clinical management issue (CMI)
Preoperative, Intraoperative, Postoperative

7. Notifications of Death
RESULTS
Surgical deaths from all hospitals*,
Notifications of Death
Fully Audited
Elective Admission
Cases with CMIs
Total CMIs
Neurosurgery
3311
2563 6%
154
(6%)
193
Urology
749
631
56% 56
(8%) 78
Vascular Surgery
2061
1622
27%
164
(10%)
226
Total
6121
4816
25%
374
497
* Excludes New South Wales

8. RESULTS – CLINICAL MANAGEMENT ISSUES (CMIs)

9. RESULTS – PREOPERATIVE CMIs (n = 261)

10. RESULTS – INTRAOPERATIVE CMIs (n = 82)

11. RESULTS – POSTOPERATIVE CMIs (n = 92)65 21 6

12. RESULTS – INADEQUATE ASSESSMENT
RESULTS – INADEQUATE ASSESSMENT -> DELAYS AT EMERGENCY DEPARTMENT (ED)
Failing to recognise symptoms
Failing to undertake appropriate investigations
Failing to transfer patient to surgical care

13. RESULTS – KEY LESSONS Avoidable issues most common preoperatively
Urology had majority elective admissions
Delay in diagnosis at Emergency Department
Communication failures
Documentation in patient notes
Communication between teams
Clinical handover

14. LIMITATIONS Subjectivity and bias Self-reporting by surgeons
Single assessor
Only feedback from surgeons
No other studies to compare our results with

15. IMPLICATIONS Input from Emergency physicians?
Awareness of potential preoperative risks?
Methods to lower preoperative issues?
Follow-up study?

16. ACKNOWLEDGEMENTS Supervisors Mr Glenn McCulloch Prof Guy Maddern
Research Collaborators
Prof Robert Fitridge, A/Prof Wendy Babidge, Mr John Miller
Ms Sasha Stewart, Ms Kimberley Cottell
Mr Ray Li, Mr Gordon Guy