Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: Method and preliminary data

Paolo Ferroli, Dario Caldiroli, Francesco Acerbi, Maurizio Scholtze, Alfonso Piro, Marco Schiariti, Eleonora F. Orena, Melina Castiglione, Morgan Broggi, Alessandro Perin, Francesco Dimeco

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


Object: Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results.Methods: In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione IstitutoNeurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed.Results: Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases).Conclusions: Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within the environment under study. Persistence and strong commitment are required to enact the culture change essential in shifting from a paradigm of infallible operators to the philosophy of errare humanum est. For this paradigm shift to be successful, contributions from aviation and human factor experts are critical.

Original languageEnglish (US)
Article numberE7
JournalNeurosurgical Focus
Issue number5
StatePublished - 2012
Externally publishedYes


  • Human factor
  • Incident
  • Near miss
  • Neurosurgery
  • Reporting system
  • Safety

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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