Wrong site neurosurgery – still a problem

Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era

“…[7][8][9][10] Despite the widespread implementation of the Universal Protocol in recent years, wrongsite surgery continues to pose a signifi-cant challenge to patient safety in the United States. [11][12][13][14][15][16][17][18] Until now, there has been an ongoing lack of reliable data about the true incidence of wrong-patient and wrongsite operations because these confidential dataderived from closed claims, sentinel event databases, or other types of surveys based on voluntary reportingmay represent just the tip of the iceberg of selected, most severe occurrences. [11][12][13]19 Previous reports [19][20][21] have revealed that only approximately one-third of all wrongsite surgery cases result in legal action and estimated that the Joint Commission sentinel event database comprises just 2% of all wrong-site procedures occurring in the United States.…”

Letter to the Editor: Interhemispheric hygroma

“…The authors supported this analysis with a survey of state medical licensing bodies inquiring of the frequency of such events and the actions taken against licensees in the event of wrong-sided brain surgery. This work provides more factual case detail than has been available previously in other reports, 7,9,11,14 with the exception of the case report from Bernstein. 2 The authors assist the profession greatly by providing their interpretation of the factors contributing to this type of error.…”

“…Given the efforts by the National Patient Safety Agency, 10,11 the Joint Commission, 8 Accreditation Canada 1 and others to eliminate site errors and side error in particular, it is both curious and disturbing that such errors continue to occur. 4,14 It is with this in mind that I wish to draw the readership's attention to psychological foundations that may underpin the human error that contributes to side errors. I am indebted to Dr. John Senders for his insights on this topic.…”

Neurosurgical checklists: a review

“…13,21,39,44,55,57 To date, no direct link between neurosurgical checklists and patient safety has been published. This lack of evidence provides motivation for the field as a whole to integrate checklists into the standard of care and to prove the worth of these lists, as other fields have.…”