The Prevalence of Wrong Level Surgery Among Spine Surgeons

Mody, Milan G.; Nourbakhsh, Ali; Stahl, Daniel L; Gibbs, Mark T.; Alfawareh, Mohammad; Garges, Kim J.

doi:10.1097/brs.0b013e31816043d1

Cited by 193 publications

(154 citation statements)

References 23 publications

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“…A recent questionnaire study by Mody et al 12 found a high prevalence of wrong-level surgeries among spine surgeons with nearly 50% of surgeons performing a wrong-level surgery during their career. Correct-level spine surgery is an important patient safety and quality-of-care issue.…”

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confidence: 99%

Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement

Upadhyaya

Chin

et al. 2012

SPI

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Object The accurate intraoperative localization of the correct thoracic spine level remains a challenging problem in both open and minimally invasive spine surgery. The authors describe a technique of using preoperatively placed percutaneous fiducial screws to localize the area of interest in the thoracic spine, and they assess the safety and efficacy of the technique. Methods To avoid wrong-level surgery in the thoracic spine, the authors preoperatively placed a percutaneous 5-mm fiducial screw at the level of intended surgery using CT guidance. Plain radiographs and CT images with reconstructed views can then be referenced in the operating room to verify the surgical level, and the fiducial screw is easily identified on intraoperative fluoroscopy. The authors compared a group of 26 patients who underwent preoperative (often outpatient) fiducial screw placement prior to open or minimally invasive thoracic spine surgery to a historical group of 26 patients who had intraoperative localization with fluoroscopy alone. Results In the treatment group of 26 patients, no complications related to fiducial screw placement occurred, and there was no incidence of wrong-level surgery. In comparison, there were no wrong-level surgeries in the historical cohort of 26 patients who underwent mini-open or open thoracic spine surgery without placement of a fiducial screw. However, the authors found that the intraoperative localization fluoroscopy time was greatly reduced when a fiducial screw localization technique was employed. Conclusions The aforementioned technique for intraoperative localization is safe, efficient, and accurate for identifying the target level in thoracic spine exposures. The fiducial marker screw can be placed using CT guidance on an outpatient basis. There is a reduction in the amount of intraoperative fluoroscopy time needed for localization in the fiducial screw group.

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confidence: 99%

Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement

Upadhyaya

Chin

et al. 2012

SPI

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“…Half of the surgeons reported that they had done 1 or more wrong level surgeries during their career (14). As this is a self-reported study and retrospective in nature, it is inferred that this is likely an underestimate of the true incidence of incorrect spine level localization.…”

Section: Discussionmentioning

confidence: 78%

“…Mody et al, conducted a survey of members of the American Academy of Neurologic Surgeons which showed that 15% reported that, at least once, they had prepared the incorrect spine level, but noticed the mistake before making the incision (14). Half of the surgeons reported that they had done 1 or more wrong level surgeries during their career (14).…”

Section: Discussionmentioning

confidence: 99%

Factors predictive of topographical accuracy in spine level localization

et al. 2017

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Background: Pre-operative spine level localization by palpation of anatomical landmarks (ribs, spinous processes) in posterior approaches for surgeries from T4 to L2 is often inaccurate. This can lead to ineffective utilization of procedural time, increased radiation dose, potentially longer skin incision and wrong level surgery. Factors affecting topographical accuracy includes body mass index (BMI) of the patient, congenital or acquired deformity and knowledge of topographical anatomy.Methods: All patients had the presumed location of their pathology marked on the skin using anatomical landmarks prior to application of the Target Tape ® (Vancouver, BC, Canada) and verification using an anterior-posterior radiograph. Potential factors predictive of accurate pre-operative spine level localization such as age, gender, BMI, palpable deformity, pathology related interspinous distance (ISPD) and pathology related skin to spinous process distance were evaluated.Results: A prospective study was performed with 30 consecutive patients undergoing posterior spine surgery (T4 to L2). Accuracy of pathology related spine level localization using anatomical landmarks was only 40%. Pathology related ISPDs of more than 10 mm and palpable deformity was significantly correlated with successful determination of spine levels using anatomical landmarks.Conclusions: This study showed that poor spine level localization using anatomical landmarks was associated with pathology related ISPDs of less than 10 mm. Conversely, patients with palpable spinal deformity have their levels easily localized.

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“…In a 2003 confidential survey, 16 % of hand surgeons reported that they had prepared to operate on the wrong site but then noticed the error prior to incision (nearmiss), and 21 % reported that they had actually performed wrong-site surgery at least once during their careers [21]. Worse, in a 2008 study, 15 % of spine surgeons reported that they had prepared the incorrect spine level at least once and noticed the mistake before making incision (near-miss), but a full 50 % had performed one or more wrong-level surgeries during their career [22]. By way of analogy, the aviation community would have to experience every other pilot landing at the wrong airport at least once in their careers; this obviously does not occur in this high reliability industry.…”

Section: Other Specialties' Challengesmentioning

confidence: 99%

Toxicology in the Service of Patient and Medication Safety: a Selected Glance at Past and Present Innovations

Smith

Farmer

2015

J. Med. Toxicol.

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Medical and medication errors remain definite threats to patients in US health care. Medical toxicologists frequently encounter patients either harmed by or at risk for harm from adverse drug events, including medication errors and inadvertent exposures. An historical perspective, as viewed through the lens of specific disciplines, can be useful to trace systemic responses to safety threats. Early efforts to address anesthesia perioperative risks and recent actions in medicine, surgery, and obstetrics to introduce checklists, communication tools, and systems approaches are reviewed. Patient safety concepts can be utilized and disseminated by toxicologists to improve medication safety and drive innovative approaches to confront patient harm. Various approaches include simulation of high-risk scenarios which might predispose to medication error, assembling multidisciplinary groups of health care providers to review events and implement mitigation strategies, and proactive patient safety rounds in clinical areas to allow frontline staff to voice concerns and introduce solutions for administration, evaluation, and implementation. We review selected lessons from the past and current innovations to achieve safe medication practice.

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The Prevalence of Wrong Level Surgery Among Spine Surgeons

Cited by 193 publications

References 23 publications

Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement

Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement

Factors predictive of topographical accuracy in spine level localization

Toxicology in the Service of Patient and Medication Safety: a Selected Glance at Past and Present Innovations

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