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.
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: