Counting the cost of negligence in neurosurgery: Lessons to be learned from 10 years of claims in the NHS.

INTRODUCTION: Despite substantial progress in modernising neurosurgery, the specialty still tops the list of medico-legal claims. Understanding the factors associated with negligence claims is vital if we are to identify areas of underperformance and subsequently improve patient safety. Here we provide data on trends in neurosurgical negligence claims over a 10-year period in England. METHODS: We used data provided by the National Health Service Litigation Authority to analyse negligence claims related to neurosurgery from the financial years 2002/2003 to 2011/2012. Using the abstracts provided, we extracted information pertaining to the underlying pathology, injury severity, nature of misadventure and claim value. RESULTS: Over the 10-year period, the annual number of claims increased significantly. In total, there were 794 negligence claims (range 50-117/year); of the 613 closed cases, 405 (66.1%) were successful. The total cost related to claims during the 10 years was £65.7 million, with a mean claim per successful case of £0.16 million (total damages, defence and claimant costs of £45.1, £6.36 and £14.3 million, respectively). Claims related to emergency cases were more costly compared to those of elective cases (£209,327 vs. £112,627; P=0.002). Spinal cases represented the most frequently litigated procedures (350; 44.1% of total), inadequate surgical performance the most common misadventure (231; 29.1%) and fatality the commonest injury implicated in claims (102; 12.8%). Negligence claims related to wrong-site surgery and cauda equina syndrome were frequently successful (26/26; 100% and 14/16; 87.5% of closed cases, respectively). CONCLUSION: In England, the number of neurosurgical negligence claims is increasing, the financial cost substantial, and the burden significant. Lessons to be learned from the study are of paramount importance to reduce future cases of negligence and improve patient care.

Excision of vestibular schwannomas--is there a learning curve and how best to demonstrate it?

OBJECTIVE: To demonstrate the existence of a learning curve in a consultant neurosurgeon's performance in excising vestibular schwannomas by plotting the cumulative sum (CUSUM) chart. Also, to evaluate the influence of new technology in the form of the facial nerve monitor (FNM) and the KTP-532 Laser on surgical performance. METHOD: Analysis was carried out on a prospectively collected data series of 102 consecutive cases of vestibular schwannomas excisions between 1986 and 2000 by a single neurosurgeon using the retrosigmoid approach. The CUSUM score chart of the surgical outcomes across the series was plotted for all and large tumour sizes separately. The changes in CUSUM scores were assessed using statistical change-point analysis. Using the multivariate logistic regression analysis, we inspected the association between use of FNM and laser on outcome. RESULTS: After the first 27 cases and coinciding with the introduction of the FNM there was a clear change in the direction of the slope of the CUSUM chart, showing a clear improving trend in performance (p = 0.09). The same phenomenon was also seen when plotting the CUSUM chart for large tumours only, although this was not statistically significant. The use of FNM reduces the risk of bad House Brakmann-score by approximately 90% for all tumours (risk of bad outcome with FNM = 3.2% and without FNM = 26.7%, odds ratio = 0.10 and 95% confidence interval (0.02-0.61), p = 0.013) after adjusting for age at operation, but no significant association was seen with the use of laser. CONCLUSION: There appears to be a learning curve in the performance of a neurosurgeon. Compared to previous reports of sequential block analysis, the CUSUM method is less arbitrary and more transparent. The CUSUM is most useful as an audit tool that can help spare patients from undesirable learning curves, and help to demonstrate good standards in appraisal and revalidation.