BMJ Qual Saf 21:432-438 doi:10.1136/bmjqs-2011-000355
  • Research and reporting methodology

Surveillance of unplanned return to the operating theatre in neurosurgery combined with a mortality–morbidity conference: results of a pilot survey

  1. Pierre Czernichow1
  1. 1Department of Epidemiology and Public Health, Rouen University Hospital, Rouen, France
  2. 2Department of Neurosurgery, Rouen University Hospital, Rouen, France
  3. 3Department of Microbiology, Rouen University Hospital, Rouen, France
  1. Correspondence to Dr Hélène Marini, Department of Epidemiology and Public Health, Rouen University Hospital, 1 rue de Germont, 76031 Rouen-Cedex, France; helene.marini{at}
  1. Contributors Dr Marini had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: HM, VM, PC. Acquisition of data: HM, CL, SD, OL, MGB, NF, FP. Analysis and interpretation of data: HM, VM, SD, VJ, PC. Drafting of the manuscript: HM. Critical revision of the manuscript for important intellectual content: HM, VM, SD, FP, PC. Statistical analysis: HM. Administrative, technical or material support: HM, VM. Study supervision: HM, VM, PC.

  • Accepted 1 January 2012
  • Published Online First 10 February 2012


Background Unplanned return to the operating theatre (UROT) is a useful trigger tool that could be used to identify surgical adverse events (SAEs). The present study describes the feasibility of SAE surveillance in neurosurgical patients, based on UROT identification, completed with SAE analysis at a morbidity–mortality conference (MMC) meeting.

Method For consecutive patients who underwent a neurosurgical procedure between 1 November 2008 and 30 April 2009, return to the operating theatre (ROT) was identified based on the hospital information system associated to prospective payment (HISPP). ROT was classified as planned or unplanned and UROT was further classified as related to the natural history of the disease or related to an adverse event (AE-UROT). MMC meetings were organised to discuss results of UROT surveillance and to analyse AE-UROT.

Results 1006 neurosurgical procedures were included in the surveillance. HISSP identified 152 ROTs, with 73 UROTs related to an SAE (7.3% (5.7% to 9.0%)): infectious SAE (n=24, 2.4% (1.5% to 3.5%)), haemorrhagic SAE (n=23, 2.3% (1.5% to 3.4%)), other cause SAE (n=26, 2.8% (1.9% to 4.0%)), and infectious and other cause SAE (n=2, 0.2% (0.0% to 0.7%)). Identification of AE-UROT through HISSP required a 4 h/month time frame. Eight UROTs related to SAE cases were discussed during MMC meetings, leading to the identification of non-conforming care processes and practical improvement actions.

Conclusion UROT related to SAE surveillance in neurosurgical patients was considered feasible. The association of surveillance and MMCs allowed staff to concentrate on the analysis of most frequent or most severe AEs and was a practical and useful tool to stimulate improvement. The impact on healthcare quality of SAE surveillance associated with MMC warrants further research.


  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available on request from the corresponding author.

Free sample

This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of BMJ Quality & Safety.
View free sample issue >>

Email alerts

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.


Navigate This Article