Abstract Background The mortality rate is low in endocrine surgery, making it a difficult outcome to use for quality improvement in individual units. Lessons from population data sets are of value in improving outcomes. Data from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) were used here to understand and elucidate potential systems issues that may contribute to preventable deaths. Methods ANZASM data relating to 30-day mortality after thyroidectomy, parathyroidectomy, and adrenalectomy from 2009 to 2020 were reviewed. Mortality rates were calculated using billing data. Thematic analysis of independent assessor reports was conducted to produce a coding framework. Results A total of 67 deaths were reported, with an estimated mortality rate of 0.03–0.07 per cent (38 for thyroidectomy (0.03–0.06 per cent), 16 for parathyroidectomy (0.03–0.06 per cent), 13 for adrenalectomy (0.15–0.33 per cent)). Twenty-seven deaths (40 per cent) were precipitated by clinically significant adverse events, and 18 (27 per cent) were judged to be preventable by independent ANZASM assessors. Recurrent themes included inadequate preoperative assessment, lack of anticipation of intraoperative pitfalls, and failure to recognize and effectively address postoperative complications. Several novel themes were reiterated, such as occult ischaemic heart disease associated with death after parathyroid surgery, unexpected intraoperative difficulties from adrenal metastasis, and complications due to anticoagulation therapy after thyroid surgery. Conclusion This study represents a large-scale national report of deaths after endocrine surgery and provides insights into these rare events. Although the overall mortality rate is low, 27 per cent of deaths involved systems issues that were preventable following independent peer review.

中文翻译：

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内分泌手术后的意外死亡：通过国家手术死亡率审计从罕见事件中吸取教训

摘要 背景内分泌手术的死亡率较低，因此很难将其用于单个单位的质量改进。人口数据集的经验教训对于改善结果很有价值。此处使用澳大利亚和新西兰手术死亡率审计 (ANZASM) 的数据来了解和阐明可能导致可预防死亡的潜在系统问题。 方法回顾了 2009 年至 2020 年与甲状腺切除术、甲状旁腺切除术和肾上腺切除术后 30 天死亡率相关的 ANZASM 数据。死亡率是使用账单数据计算的。对独立评估者报告进行主题分析以产生编码框架。 结果总共报告了 67 例死亡，估计死亡率为 0.03-0.07%（甲状腺切除术 38 例（0.03-0.06%），甲状旁腺切除术 16 例（0.03-0.06%），肾上腺切除术 13 例（0.15-0.33%）。分））。27 例死亡（40%）是由临床上显着的不良事件引起的，独立的 ANZASM 评估人员认为 18 例（27%）死亡是可以预防的。反复出现的主题包括术前评估不足、缺乏对术中陷阱的预期以及未能识别和有效解决术后并发症。重申了几个新的主题，例如与甲状旁腺手术后死亡相关的隐匿性缺血性心脏病、肾上腺转移引起的意外术中困难以及甲状腺手术后抗凝治疗引起的并发症。 结论这项研究代表了内分泌手术后死亡的大规模全国报告，并提供了对这些罕见事件的见解。尽管总体死亡率较低，但 27% 的死亡涉及系统问题，而这些问题在独立同行审查后是可以预防的。