Recording Medical Errors in Brain Tumor Surgery Can Facilitate Their Avoidance: Single Institution Comparative Cohort Analysis over 19 Years

Objectives: Error-tracking studies have become an invaluable tool for gaining deeper insights into the patterns, causes, and clinical consequences of errors. In this paper, we examine the long-term impact of analyzing errors at the level of an individual surgeon. Methods: We performed a retrospective analysis of an internally maintained prospective database from September 2013 to April 2019 (Group C). These variables were compared with two earlier cohorts: Group A (2000–2006) and Group B (2006–2013). The key endpoints assessed included error incidence, type, severity, preventability, and clinical impact. The study also investigated the potential seasonal variations in error incidence, considering the rotation of trainees. Results: A persistent decrease in the mean errors/case (across all types) since records began in 2000 was noted; (1.8 for study group C versus 1.9 and 2.4 for group B and group A respectively, p = 0.048). We observed a drop in error severity score (major errors of 17.5% versus 29.5% and 22.6% respectively, p < 0.00001) and clinical impact (high impact in 0.4% versus 1.0% and 2.7% respectively, p < 0.00001). Conclusions: Ongoing and systematic error tracking and analysis seem to have a lasting impact on reducing both the incidence and severity of errors. These positive outcomes are thought to reflect the establishment of a culture of safety, fostering transparency and constructive feedback within the broader surgical team.