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Wrong Site Spine Surgery in the Veterans Administration.
Bradley V Watts1,2,3, Jacob R Rachlin4, William Gunnar5,6
1VA National Center for Patient Safety, Ann Arbor, MI.
Clinical Spine Surgery
|January 15, 2019
Summary
Wrong level spine surgery remains a significant safety concern. Poor radiograph quality and intraoperative marker issues were the most common causes, highlighting the need for improved imaging practices.
Area of Science:
- Neurosurgery
- Patient Safety
- Health Administration
Background:
- Wrong site surgery is a frequent event reported to The Joint Commission.
- Spine surgery errors can lead to significant patient harm.
- Approximately 50% of spine surgeons encounter at least one wrong-site surgery during their careers.
Purpose of the Study:
- Determine the occurrence frequency of incorrect spine level surgery within the Veterans Health Administration (VHA).
- Identify causal factors contributing to these surgical errors.
- Propose actionable solutions to mitigate wrong-level spine surgeries.
Main Methods:
- Descriptive analysis of wrong level spinal surgery incidents reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017.
- Calculation of wrong-site spine surgery rates, including specific rates for orthopedic and neurosurgical procedures.
- Review of root cause analyses for identified cases.
Main Results:
- 32 cases of wrong-site spine surgery were reported between 2000 and 2017.
- Cervical, lumbar, and thoracic regions were affected in 14, 13, and 5 cases, respectively.
- The primary root causes identified were issues with radiographs (69%) and intraoperative markers (69%).
Conclusions:
- Wrong level spine surgery persists as a critical safety issue, even with adherence to existing guidelines.
- Optimizing radiograph quality and interpretation accuracy is crucial for preventing these errors.
- Targeted interventions addressing imaging protocols are recommended to enhance patient safety in spine surgery.
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