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

Restricted access


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.


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.


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.


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.

Abbreviations used in this paper:ICSS = incorrect-site surgery; JCAHO = Joint Commission on Accreditation of Healthcare Organizations.

Article Information

Address correspondence to: Neil Duggal, M.D., M.Sc., F.R.C.S.C. Division of Neurosurgery, The University of Western Ontario, London Health Sciences Centre, University Campus, Room A10–307, 339 Windermere Road, London, Ontario, N6A 5A5 Canada. email: Neil.Duggal@lhsc.on.ca.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Pie charts indicating how often patients were informed of ICSS made during a 12-month period for wrong-sided craniotomies (A) and wrong-level discectomies (B).

  • View in gallery

    Pie charts revealing factors related to wrong-sided cranial surgery. Factors specifically related to wrong-sided cranial surgery were emergency operating conditions or surgery performed after hours (68% of cases, A), fatigue (19% of cases, B), and unusual time pressures to start or finish a procedure (42% of cases, C).

  • View in gallery

    Pie charts showing factors related to wrong-level spinal surgery. Factors specifically related to wrong-level spinal surgery included failure to use intraoperative x-ray films or image guidance to confirm spinal level (30% of cases, A) and unusual patient anatomy or physical characteristics (38% of cases, B).


  • 1

    Anonymous: Doctor who cut off wrong leg is defended by colleagues. New York Times September171995

  • 2

    Brennan TA: The Institute of Medicine report on medical errors—could it do harm?. N Engl J Med 342:112311252000

  • 3

    Gostin L: A public health approach to reducing error: medical malpractice as a barrier. JAMA 283:174217432000

  • 4

    Johnson P: Wrong site surgery in orthopedics: analysis of 15,987 cases at the orthopedic institute in Fargo. Annual Meeting of the American Academy of Orthopaedic Surgeons 2000

    • Search Google Scholar
    • Export Citation
  • 5

    Joint Commission on Accreditation of Healthcare Organizations: A follow-up review of wrong site surgery. Sentinel Event Alert Dec 5:132001

    • Search Google Scholar
    • Export Citation
  • 6

    Joint Commission on Accreditation of Healthcare Organizations: Lessons learned: wrong site surgery. Sentinel Event Alert Aug 28:121998

    • Search Google Scholar
    • Export Citation
  • 7

    Meinberg EGStern PJ: Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am 85:1931972003

  • 8

    Miller S: Two feet of mistakes. Medicine: how to police serious errors by doctors?. Newsweek March271995

  • 9

    Mohr JC: American medical malpractice litigation in historical perspective. JAMA 283:173117372000

  • 10

    Richard J: Identifying ways to reduce surgical errors. JAMA 275:351996

  • 11

    Stanley D: Amputee recovering after wrong leg taken. Tampa Tribune February282001

  • 12

    Sullivan P: Warning for surgeons: measure twice, cut once. CMAJ 168:10292003




All Time Past Year Past 30 Days
Abstract Views 256 256 23
Full Text Views 94 78 1
PDF Downloads 123 101 0
EPUB Downloads 0 0 0


Google Scholar