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Balraj S. Jhawar, Demytra Mitsis and Neil Duggal

Object

Perhaps the single greatest error that a surgeon hopes to avoid is operating at the wrong site. In this report, the authors describe the incidence and possible determinants of incorrect-site surgery (ICSS) among neurosurgeons.

Methods

The authors asked neurosurgeons to complete an anonymous survey. These surgeons were asked to report the number of craniotomies and lumbar and cervical discectomies performed during the previous year, as well as whether ICSS had occurred. They were also asked detailed questions regarding the potential determinants of ICSS.

Results

There was a 75% response rate and a 68% survey completion rate. Participating neurosurgeons performed 4695 lumbar and 2649 cervical discectomies, as well as 10,203 craniotomies. Based on this self-reporting, the incidence of wrong-level lumbar surgery was estimated to be 4.5 occurrences per 10,000 operations. The ICSSs per 10,000 cervical discectomies and craniotomies were 6.8 and 2.2, respectively. Neurosurgeons recognized fatigue, unusual time pressure, and emergent operations as factors contributing to ICSS. For spine surgery, in particular, unusual patient anatomy and a failure to verify the operative site by radiography were also commonly reported contributors.

Conclusions

Neurosurgical ICSSs do occur, but are rare events. Although there are significant limitations to the survey-based methodology, the data suggest that the prevention of such errors will require neurosurgeons to recognize risk factors and increase the use of intraoperative imaging.

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.3171/SPI/2008/9/7/104 SPI_2008_9_7_104 Wrong-Sided Surgery Joshua M. Ammerman Matthew D. Ammerman 7 2008 9 1 105 106 10.3171/SPI/2008/9/7/105 SPI_2008_9_7_105 Wrong-Sided Surgery Ramesh Sahjpaul 7 2008 9 1 106 106 10.3171/SPI/2008/9/7/106 SPI_2008_9_7_106 Wrong-Sided Surgery Claudio Irace Luigi Giannachi Susanna Usai Claudio Corona 7 2008 9 1 107 107 10.3171/SPI/2008/9/7/107 SPI_2008_9_7_107 Erratum Balraj S. Jhawar Neil Duggal 7 2008 9 1 109 109 10.3171/SPI/2008/8/7/109 SPI_2008_8_7_109 J Neurosurg Spine Journal of Neurosurgery: Spine 1547

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Joshua M. Ammerman and Matthew D. Ammerman

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Ramesh Sahjpaul

prevent wrong-site surgery but it will help to prevent wrong-sided surgery. In addition, routine use of intraoperative imaging guidance, where applicable, essentially eliminates wrong-site craniotomy. Whereas the authors correctly observe that external spinal landmarks do not readily identify surgical levels, we have found it useful to mark the planned level and side to the best approximation as this provides yet another checkpoint to reduce the risk of wrong-level and wrong-sided surgery. We have adopted an additional “concluding time-out” component that occurs at the

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Claudio Irace, Luigi Giannachi, Susanna Usai and Claudio Corona

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Claudio Irace and Claudio Corona

, Giannachi L , Usai S , Corona C : Wrong-sided surgery . J Neurosurg Spine 9 : 107 – 108 , 2008 . (Letter) 10 Jhawar BS , Mitsis D , Duggal N : Wrong-sided and wrong-level neurosurgery: a national survey . J Neurosurg Spine 7 : 467 – 472 , 2007 11 Joint Commission on the Accreditation of Healthcare Organizations (USA) : 2004 Universal Protocol ( http://www.jointcommission.org/PatientSafety/NationalPatientSafety-Goals/04_npsgs.htm ) [Accessed February 2, 2010] 12 Krämer J : Micro- or macrodiscotomy for open lumbar disc surgery? . Eur

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Editorial

Wrong-site craniotomy

Robert R. Cima

injury was the sort that would not occur unless someone was negligent. For the majority of these wrong-side surgeries, this is an incorrect view. However, hospitals, physicians, and insurers are often quick to negotiate away these errors to avoid publicity or jury verdicts with restrictions preventing the public release of information. This leads to a lack of understanding regarding the many potential causes of these wrong-side surgeries, which could be used to educate providers and improve systems in the hope of avoiding repetition of these errors in other patients

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Fred. L. Cohen, Daniel Mendelsohn and Mark Bernstein

9 Bernstein M : Wrong-side surgery: systems for prevention . Can J Surg 46 : 144 – 146 , 2003 10 Blackhurst D : Doctors cut into wrong side of my head . The Sentinel December 28 2007 11 Board of Medical Licensure and Discipline : In the matter of XXX. MD XXX:MD09027 2007 12 Brain surgeon who made mistake is reinstated . New York Times October 4 1995 13 Center treats wrong side of patient's brain. Patient treated at cancer center. October 30 2007 . ( http://www.newsnet5.com/print/14455533/detail.html ) [Accessed November 13, 2009] 14

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David Cochrane

materials or methods used in this study or the findings specified in this paper. References 1 Accreditation Canada : Surgical Checklist Ottawa, Ontario , Accreditation Canada , 2010 . ( http://www.accreditation.ca/knowledge-exchange/patient-safety/surgical-checklist ) [Accessed April 6, 2011] 2 Bernstein M : Wrong-side surgery: systems for prevention . Can J Surg 46 : 144 – 146 , 2003 3 Cima RR , Hale C , Kollengode A , Rogers JC , Cassivi SD , Deschamps C : Surgical case listing accuracy: failure analysis at a high-volume academic

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Matthew J. Tormenti, Matthew B. Maserati, Christopher M. Bonfield, Peter C. Gerszten, John J. Moossy, Adam S. Kanter, Richard M. Spiro and David O. Okonkwo

sequelae. Wrong-Level Surgery The reported incidence of wrong-level surgery in the lumbar spine ranges from 0.03% to 0.04%. 1 , 21 Although adherence to the preoperative timeout process, review of relevant radiographs, and intraoperative localization have helped decrease rates of wrong-level and wrong-side surgery, wrong-level surgery is not preventable in all cases. One patient (0.2%) in our series underwent laminectomy and partial medial facetectomy at an unintended level before the improper localization was realized; TLIF was performed as planned at the level