Wrong Site Spine Surgery in the Veterans Administration

Abstract

Study Design: Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA). Objective: To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue. Summary of Background Data: Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients. Materials and Methods: We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated. Results: There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues. Conclusions: Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.

A perspective on wrong level, wrong side, and wrong site spine surgery

“…Notably, 50-67% of spine surgeons have directly experienced WLS over their careers [Table 1]. [12,14,20] Mody et al (2008) observed that 207 (50%) neurosurgeons had experienced WLS (spinal) once or more during their careers; the overall incidence was 1/3110 spinal cases. [14] Watts et al (2019) reported the same 50% incidence of WLS over spine surgeons' careers, a frequency distinctly unchanged by the 11 year interval between the two studies.…”

“…[14] Watts et al (2019) reported the same 50% incidence of WLS over spine surgeons' careers, a frequency distinctly unchanged by the 11 year interval between the two studies. [20] Interestingly, Mayer et al (2014) reported a higher 67% incidence of WLS involving thoracolumbar procedures over surgeons' careers; this frequency was somewhat higher utilizing X-ray (56%) alone vs. fluoroscopy (44%) to intraoperatively confirm the correct spinal operative levels. [12]…”

“…includes wrong site surgery (WSS) as well). [1,2,[4][5][6][7][8][9][10]13,14,16,18,19,20] Although routine use of the Universal Protocol, Time-Outs, and the 3 R's (i.e. right patient, right procedure, right location/side) should largely limit/eliminate the first two "errors, " WLS and WSS still occur with an unacceptable frequency.…”

“…right patient, right procedure, right location/side) should largely limit/eliminate the first two "errors, " WLS and WSS still occur with an unacceptable frequency. [1,2,[4][5][6][7]10,12,14,[16][17][18][19][20] Here, we reviewed the incidence of WLS and WSS in 20 studies, and looked at the major factors contributing to these "errors;" spinal anomalies/anatomic variants, and failure to obtain adequate intraoperative X-rays/Fluoroscopic images (i.e. inadequate number, inadequate quality, poor/misinterpretation of X-rays/fluoroscopic images).…”

“…failure to "speak up"), fatigue, rushing/ emergent procedures, and others). [1,2,[4][5][6][7]10,12,14,[16][17][18][19][20] Our aim in highlighting the main failures contributing to WLS/WSS/WSSS should help limit/eliminate them in the future.…”