Wrong-sided and wrong-level neurosurgery: a national survey

Jhawar, Balraj S.; Mitsis, Demytra; Duggal, Neil

doi:10.3171/spi-07/11/467

Cited by 105 publications

(36 citation statements)

References 5 publications

(1 reference statement)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…[19–23] As some studies have found, almost 50% of spine surgeons report that they have performed surgery at an incorrect vertebral level during their careers. [10,11] The variable anatomy of patients has been considered a cause in up to 40% of cases. [10,11,24] …”

Section: Discussionmentioning

confidence: 99%

“…[10] Nearly half of surveyed spine surgeons responded that they had performed surgery at an incorrect vertebral level during their careers. [11] Unusual patient anatomy and a failure to verify the operative site on radiography have been commonly reported. [10,11] Therefore, it is necessary to count thoracic–lumbar vertebrae preoperatively to avoid wrong-level surgery in the course of scoliosis correction due to the variation in vertebral number.…”

Section: Introductionmentioning

confidence: 99%

“…[11] Unusual patient anatomy and a failure to verify the operative site on radiography have been commonly reported. [10,11] Therefore, it is necessary to count thoracic–lumbar vertebrae preoperatively to avoid wrong-level surgery in the course of scoliosis correction due to the variation in vertebral number. Recently, Ibrahim et al [12] reported for the first time that variations in the numbers of thoracic or lumbar vertebrae were found in 10% of patients with AIS.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

A neglected point in surgical treatment of adolescent idiopathic scoliosis

Zhang²,

Zhao³

et al. 2016

Medicine

View full text Add to dashboard Cite

Inaccurate identification of vertebral levels is the main cause of wrong-site spine surgery which is performed by nearly half of the spine surgeons. Unusual anatomy and failure to verify the surgical level on radiographs have been commonly reported. We aimed at investigating the variations in vertebral number in adolescent idiopathic scoliosis (AIS) patients and thus to raise awareness of the possibility for wrong-level spinal surgery and to make a comparison with normal adolescents. A cohort of 657 AIS patients and 248 normal adolescents, presented to our center from June 2008 to February 2013, who met the inclusion criteria, were recruited. Radiographs were reviewed to identify the number of thoracic or lumbar vertebrae and the presence of a lumbosacral transitional vertebra. In the AIS group, 70 (10.6%) patients had variations in the number of thoracic and/or lumbar vertebrae. Remarkably, the prevalence of variations in male subjects was significantly higher than that in female subjects (P < 0.05). Thirty-seven patients (5.6%) had an atypical number of thoracic vertebrae, with 33 having 11 thoracic vertebrae and 4 patients having 13. Forty-eight patients (7.3%) had an atypical number of lumbar vertebrae, with 14 having 4 lumbar vertebrae and 34 patients having 6. Multilevel vertebral anomalies were present in 2.3% of the patients (15 of 657). A variation in the number of vertebrae had been identified in 1.7% (11) of the reports by the radiologist. In the normal group, 27 (10.9%) subjects showed variations in the vertebral number. There was no significant difference in the prevalence of atypical numbers of vertebral number between the AIS and normal groups (P > 0.05). Therefore, we concluded that variations in the number of thoracic–lumbar vertebrae were found in up to10.6% of AIS patients. Identification of variations in the number of vertebrae is crucial to serve to decrease the risk of wrong-level surgery.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

A neglected point in surgical treatment of adolescent idiopathic scoliosis

Zhang²,

Zhao³

et al. 2016

Medicine

View full text Add to dashboard Cite

show abstract

“…These errors, which involve the intraoperative verification of the surgical patients by the surgeon after the timeout before the first incision, included faulty counting methods due to abnormal spinal anatomy, failure to use intraoperative images during the procedure, inverting the intraoperative images, and misinterpreting cloudy images without consulting radiology(18, 25, 34, 39, 43–49). …”

Section: Resultsmentioning

confidence: 99%

Applying fault tree analysis to the prevention of wrong-site surgery

Abecassis

McElroy

Patel

et al. 2015

Journal of Surgical Research

View full text Add to dashboard Cite

Wrong Site Surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS, and used the results to perform a fault tree analysis in order to assess the reliability of the system in preventing (WSS) and identify high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for Wrong Site Surgery. The fault tree contains 35 faults, the majority of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing and a brief timeout, a large proportion of the process relies on human transcription and verification. Fault Tree Analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.

show abstract

“…In a neurosurgical study [6], ∼ 25 % of all neurosurgeons reported having performed the skin incision at the wrong level for intervertebral disk surgery. Statistics provided by the Federal Medical Society from 2008 to date include qualitative data about the type of potential medical error and the number of reported errors.…”

Section: Introductionmentioning

confidence: 99%