Literature DB >> 22480979

A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to help avoid these errors.

Michael W Groff1, Joshua E Heller, Eric A Potts, Praveen V Mummaneni, Christopher I Shaffrey, Justin S Smith.   

Abstract

OBJECTIVE: To understand better the scope of wrong-level lumbar spine surgery and current practices in place to help avoid such errors.
METHODS: The Joint Section on Disorders of the Spine and Peripheral Nerves (Spine Section) developed a survey on single-level lumbar spine decompression surgery. Invitations to complete the Web-based survey were sent to all Spine Section members. Respondents were assured of confidentiality.
RESULTS: There were 569 responses from 1045 requests (54%). Most surgeons either routinely (74%) or sometimes (11%) obtain preoperative imaging for incision planning. Most surgeons indicated that they obtained imaging after the incision was performed for localization either routinely before bone removal (73%) or most frequently before bone removal but occasionally after (16%). Almost 50% of reporting surgeons have performed wrong-level lumbar spine surgery at least once, and >10% have performed wrong-side lumbar spine surgery at least once. Nearly 20% of responding surgeons have been the subject of at least one malpractice case relating to these errors. Only 40% of respondents believed that the site marking/"time out" protocol of The Joint Commission on the Accreditation of Healthcare Organizations has led to a reduction in these errors.
CONCLUSIONS: There is substantial heterogeneity in approaches used to localize operative levels in the lumbar spine. Existing safety protocols may not be mitigating wrong-level surgery to the extent previously thought.
Copyright © 2013 Elsevier Inc. All rights reserved.

Mesh:

Year:  2012        PMID: 22480979     DOI: 10.1016/j.wneu.2012.03.017

Source DB:  PubMed          Journal:  World Neurosurg        ISSN: 1878-8750            Impact factor:   2.104


  5 in total

1.  Performance evaluation of MIND demons deformable registration of MR and CT images in spinal interventions.

Authors:  S Reaungamornrat; T De Silva; A Uneri; J Goerres; M Jacobson; M Ketcha; S Vogt; G Kleinszig; A J Khanna; J-P Wolinsky; J L Prince; J H Siewerdsen
Journal:  Phys Med Biol       Date:  2016-11-03       Impact factor: 3.609

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

Authors:  Zachary A Abecassis; Lisa M McElroy; Ronak M Patel; Rebeca Khorzad; Charles Carroll; Sanjay Mehrotra
Journal:  J Surg Res       Date:  2014-09-06       Impact factor: 2.192

3.  Abnormal rib count in scoliosis surgery: impact on the reporting of spinal fusion levels.

Authors:  Hillard T Spencer; Meryl E Gold; M Timothy Hresko
Journal:  J Child Orthop       Date:  2014-11-05       Impact factor: 1.548

4.  Radiograms Obtained during Anterior Cervical Decompression and Fusion Can Mislead Surgeons into Performing Surgery at the Wrong Level.

Authors:  Chikato Mannoji; Masao Koda; Takeo Furuya; Yuzuru Okamoto; Tamiyo Kon; Kazuhisa Takahashi; Masashi Yamazaki; Masazumi Murakami
Journal:  Case Rep Orthop       Date:  2014-10-16

5.  Medical Malpractice Claims and Mitigation Strategies Following Spine Surgery.

Authors:  Keith L Jackson; Jacob Rumley; Matthew Griffith; Timothy R Linkous; Uzondu Agochukwu; John DeVine
Journal:  Global Spine J       Date:  2020-08-07
  5 in total

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