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McCartney W, Ober C, Yiapanis C. Accurate Preoperative Localization of Thoracolumbar Disc Extrusion in Dogs: A Prospective Controlled Study. Vet Sci 2024; 11:434. [PMID: 39330813 PMCID: PMC11435586 DOI: 10.3390/vetsci11090434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/27/2024] [Accepted: 09/12/2024] [Indexed: 09/28/2024] Open
Abstract
Intervertebral disc disease (IVDD) is a very common cause of spinal cord compression in dogs. The errors of human surgeons operating on the wrong level or wrong side is a recognized problem and has been largely analyzed. To date, little information is available regarding these errors in dogs. The objective of this study was to assess the accuracy of disc localization prior to possible surgery for IVDD to ensure the surgeon begins their incision directly over the extruded disc. Eighty-five chondrodystrophic or brachycephalic dogs that presented with IVDD confirmed by CT or MRI scan were included in the study. Two small Backhaus clamps were placed cranial and caudal to the lesion site and a control clamp placed at the wing of the ilium. The main interest was whether the surgeon was able to preoperatively pinpoint the correct site for the surgery. Dorsoventral radiographs were taken to verify by another person if the clamps had been placed in the correct position. If the result was incorrect, the surgeon was asked to try again without knowing that the clamps were incorrect, and another radiograph was taken. This was repeated until the position was correct. The results were recorded as correct or incorrect and the number of attempts were registered. The results suggested no significant trend over time for any of the outcomes examined. There were some slight improvements over time, but none of the results was close to statistical significance. The findings of the study showed that in the thoracolumbar region the surgeon has a higher chance of incorrectly marking the exact site for surgery.
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Affiliation(s)
| | - Ciprian Ober
- Faculty of Veterinary Medicine, Department of Surgery, University of Agricultural Sciences and Veterinary Medicine, 400372 Cluj-Napoca, Romania
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Hem S, Padilla-Lichtenberger FL, Borensztein M, Del Valle J, Landriel F. A Novel Marking Technique for Accurate Minimal Invasive Approaches in Spine Tumor Surgeries With Activated Carbon Marking. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01244. [PMID: 38995036 DOI: 10.1227/ons.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/15/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To describe a novel, practical, reproducible, and effective preoperative marking technique for accurate localization of the spinal level in a series of patients with tumor lesions. METHODS We retrospectively analyzed patients undergoing minimally invasive (MIS) surgery for spine tumors from 2016 to 2021, in which this marking technique was used. Twenty-one patients, with tumor lesions involving difficult radioscopic visualization (cervicothoracic junction or upper dorsal spine, C6-T8), were included. Tumor lesion level was previously determined with enhanced MRI in all cases. Twenty-four to forty-eight hours before surgery, computed tomography image-guided carbon marking was performed by administration of aqueous suspension of carbon with a 21-gauge needle placed resembling the MIS approach planned trajectory. During surgery, activated carbon marking was followed until reaching the final target on the bone. Next, sequential dilators and an MIS retractor were placed. Then, bone resection and tumor exeresis were performed according to the case. RESULTS Average age was 60.6 years (26-76 years). Fifteen (71%) patients were women. In most cases (76%), tumor pathology involved intradural lesions (meningiomas and schwannomas). In all cases, the marking described allowed to accurately guide the MIS approach to tumor site. Neither intraoperative fluoroscopy nor approach enlargement was required in any procedure. Postoperative complications were reported in only 4 patients, none related with the marking. CONCLUSION Computed tomography image-guided activated carbon marking allows to accurately lead MIS approaches in a practical, reproducible, and effective way in cases of tumors localized in regions of the spine of difficult radioscopic visualization.
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Affiliation(s)
- Santiago Hem
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Matias Borensztein
- Diagnostic Imaging Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Del Valle
- Diagnostic Imaging Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Federico Landriel
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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3
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Concepción-González A, Sarmiento JM, Rymond CC, Ezeh C, Sinha R, Lin H, Lu K, Boby AZ, Gorroochurn P, Larson AN, Roye BD, Ilharreborde B, Vitale MG. Evaluating compliance with the best practice guidelines for wrong-level surgery prevention in high-risk pediatric spine surgery. Spine Deform 2024; 12:923-932. [PMID: 38512566 DOI: 10.1007/s43390-024-00836-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/01/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE In 2018, Best Practice Guidelines (BPGs) were published for preventing wrong-level surgery in pediatric spinal deformity, but successful implementation has not been established. The purpose of this study was to evaluate BPG compliance 5 years after publication. We hypothesized higher compliance among BPG authors and among surgeons with more experience, higher caseload, and awareness of the BPGs. METHODS We queried North American and European surgeons, authors and nonauthors, and members of pediatric spinal study groups on adherence to BPGs using an anonymous survey consisting of 18 Likert scale questions. Respondents provided years in practice, yearly caseload, and guideline awareness. Mean compliance scores (MCS) were developed by correlating Likert responses with MCS scores ("None of the time" = no compliance = MCS 0, "Sometimes" = weak to moderate = MCS 1, "Most of the time" = high = MCS 2, and "All the time" = perfect = MCS 3). RESULTS Of the 134 respondents, 81.5% reported high or perfect compliance. Average MCS for all guidelines was 2.4 ± 0.4. North American and European surgeons showed no compliance differences (2.4 vs. 2.3, p = 0.07). Authors and nonauthors showed significantly different compliance scores (2.8 vs 2.4, p < 0.001), as did surgeons with and without knowledge of the BPGs (2.5 vs 2.2, p < 0.001). BPG awareness and compliance showed a moderate positive correlation (r = 0.48, p < 0.001), with non-significant associations between compliance and both years in practice (r = 0.41, p = 0.64) and yearly caseload (r = 0.02, p = 0.87). CONCLUSION Surgeons reported high or perfect compliance 81.5% of the time with BPGs for preventing wrong-level surgery. Authorship and BPG awareness showed increased compliance. Location, study group membership, years in practice, and yearly caseload did not affect compliance. LEVEL OF EVIDENCE Level V-expert opinion.
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Affiliation(s)
- Alondra Concepción-González
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA.
- Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, ATTN: Alondra Concepción-González, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA.
| | - J Manuel Sarmiento
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
- Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Christina C Rymond
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Chinenye Ezeh
- Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Rishi Sinha
- David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Hannah Lin
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Kevin Lu
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Afrain Z Boby
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | | | - A Noelle Larson
- Division of Pediatric Orthopaedic Surgery, Mayo Clinic, Rochester, MN, 55902, USA
| | - Benjamin D Roye
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
- Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Brice Ilharreborde
- Pediatric Orthopaedic Department, Robert Debré Hospital, APHP, Cité University, Paris, Paris, France
| | - Michael G Vitale
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
- Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
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Bowman CL, De Gorter R, Zaslow J, Fortier JH, Garber G. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. BMJ Open Qual 2023; 12:e002264. [PMID: 37364940 PMCID: PMC10314656 DOI: 10.1136/bmjoq-2023-002264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable? METHODS For this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework. RESULTS Our analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as 'wholly preventable'. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy). CONCLUSIONS To improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.
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Affiliation(s)
- Cara L Bowman
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Ria De Gorter
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Joanna Zaslow
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Jacqueline H Fortier
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Gary Garber
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
- Department of Medicine, and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Petragallo R, Bertram P, Halvorsen P, Iftimia I, Low DA, Morin O, Narayanasamy G, Saenz DL, Sukumar KN, Valdes G, Weinstein L, Wells MC, Ziemer BP, Lamb JM. Development and multi-institutional validation of a convolutional neural network to detect vertebral body mis-alignments in 2D x-ray setup images. Med Phys 2023; 50:2662-2671. [PMID: 36908243 DOI: 10.1002/mp.16359] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Misalignment to the incorrect vertebral body remains a rare but serious patient safety risk in image-guided radiotherapy (IGRT). PURPOSE Our group has proposed that an automated image-review algorithm be inserted into the IGRT process as an interlock to detect off-by-one vertebral body errors. This study presents the development and multi-institutional validation of a convolutional neural network (CNN)-based approach for such an algorithm using patient image data from a planar stereoscopic x-ray IGRT system. METHODS X-rays and digitally reconstructed radiographs (DRRs) were collected from 429 spine radiotherapy patients (1592 treatment fractions) treated at six institutions using a stereoscopic x-ray image guidance system. Clinically-applied, physician approved, alignments were used for true-negative, "no-error" cases. "Off-by-one vertebral body" errors were simulated by translating DRRs along the spinal column using a semi-automated method. A leave-one-institution-out approach was used to estimate model accuracy on data from unseen institutions as follows: All of the images from five of the institutions were used to train a CNN model from scratch using a fixed network architecture and hyper-parameters. The size of this training set ranged from 5700 to 9372 images, depending on exactly which five institutions were contributing data. The training set was randomized and split using a 75/25 split into the final training/ validation sets. X-ray/ DRR image pairs and the associated binary labels of "no-error" or "shift" were used as the model input. Model accuracy was evaluated using images from the sixth institution, which were left out of the training phase entirely. This test set ranged from 180 to 3852 images, again depending on which institution had been left out of the training phase. The trained model was used to classify the images from the test set as either "no-error" or "shifted", and the model predictions were compared to the ground truth labels to assess the model accuracy. This process was repeated until each institution's images had been used as the testing dataset. RESULTS When the six models were used to classify unseen image pairs from the institution left out during training, the resulting receiver operating characteristic area under the curve values ranged from 0.976 to 0.998. With the specificity fixed at 99%, the corresponding sensitivities ranged from 61.9% to 99.2% (mean: 77.6%). With the specificity fixed at 95%, sensitivities ranged from 85.5% to 99.8% (mean: 92.9%). CONCLUSION This study demonstrated the CNN-based vertebral body misalignment model is robust when applied to previously unseen test data from an outside institution, indicating that this proposed additional safeguard against misalignment is feasible.
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Affiliation(s)
- Rachel Petragallo
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | | | - Per Halvorsen
- Department of Radiation Oncology, Beth Israel - Lahey Health, Burlington, Massachusetts, USA
| | - Ileana Iftimia
- Department of Radiation Oncology, Beth Israel - Lahey Health, Burlington, Massachusetts, USA
| | - Daniel A Low
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Olivier Morin
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Ganesh Narayanasamy
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Daniel L Saenz
- Department of Radiation Oncology, University of Texas HSC SA, San Antonio, Texas, USA
| | - Kevinraj N Sukumar
- Department of Radiation Oncology, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Gilmer Valdes
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Lauren Weinstein
- Department of Radiation Oncology, Kaiser Permanente, South San Francisco, California, USA
| | - Michelle C Wells
- Department of Radiation Oncology, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Benjamin P Ziemer
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - James M Lamb
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
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Arif H, Razzouk J, Bohen D, Ramos O, Danisa O, Cheng W. Analysis of the Reasons for Medical Malpractice Litigation Due to Facet Injections. Cureus 2023; 15:e35015. [PMID: 36938213 PMCID: PMC10022475 DOI: 10.7759/cureus.35015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
Introduction As the use of facet joint injections (FJI) increases, practitioners performing FJI may be at increased risk of legal liability. Malpractice claim analysis is performed by several specialties as it provides valuable insight into patient values and methods to mitigate the risk of malpractice litigation pertaining to a specific procedure or treatment. Malpractice analysis regarding FJI may provide clinicians with a better understanding of the reasons that lead to malpractice due to FJI, thereby allowing practitioners to improve the quality of care delivered to patients whilst mitigating the incidence of malpractice. The aim of our study was to analyze the reasons for malpractice litigation due to FJI by querying Westlaw and VerdictSearch, two well-established legal databases widely used in medicolegal research. Methods We queried the Westlaw Edge and VerdictSearch legal databases utilizing the terms "facet injection" and "spine". Our database queries yielded 1026 results on Westlaw Edge and 545 results on VerdictSearch. Cases were reviewed and categorized by two independent reviewers based on the grievance(s) levied by the plaintiff. Discrepancies between reviewers were resolved by a third reviewer. Inclusion criteria for case relevance were defined as a basis of litigation resting on malpractice claims filed between the years 2000-2022 directly pertaining to FJI. Additional data collected included the date of the case hearing, verdict ruling, location of filed claim, payment or settlement amount, and sustained injuries. Results Of all 1571 cases reviewed, 1568 cases were excluded due to a basis of litigation unrelated to FJI. Of the three cases pertaining to FJI, the first case involved an alleged procedural error on the part of the anesthesiologist, whereby the anesthesiologist misplaced the needle during FJI, resulting in quadriplegia due to a cervical spine infarction. The plaintiff also contended that the pre-procedural timeout was improperly conducted as the practitioner utilized iohexol as the injected contrast material despite the patient's well-documented allergy to iohexol. The jury deemed both the practitioner and hospital negligent, and a plaintiff verdict was issued. The second case was filed under a basis of litigation alleging delayed diagnosis and treatment on the part of an emergency medicine physician. The court acquitted the physician, and a defense verdict was issued. The third case was filed under a basis of litigation of alleged deviation from the standard of care on the part of the anesthesiologist, whereby the anesthesiologist performing the FJI did not use fluoroscopy. The court affirmed fluoroscopy is not dictated as the standard of care for FJI and issued a defendant verdict. Conclusion This study provides insight into the risk of medical malpractice suits brought on by facet joint injection. Our findings suggest that despite the high prevalence of facet joint injections performed annually, there is limited legal liability associated with the procedure. Nevertheless, there are certain reasons a malpractice claim may be filed due to facet injection, including gross procedural error resulting in patient paralysis, delay in treatment or diagnosis, and deviation from the established standard of care. As such, treatment decisions regarding facet joint injection should not be influenced by medicolegal concerns and remain predicated on patient care needs and standard of care.
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Affiliation(s)
- Haad Arif
- Medicine, University of California Riverside School of Medicine, Riverside, USA
| | - Jacob Razzouk
- Medicine, Loma Linda University School of Medicine, Loma Linda, USA
| | - Daniel Bohen
- Biomedical Engineering, University of Southern California Viterbi School of Engineering, Los Angeles, USA
| | - Omar Ramos
- Orthopaedic Surgery, Twin Cities Spine Center, Minneapolis, USA
| | - Olumide Danisa
- Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Wayne Cheng
- Orthopedic Surgery, Jerry L Pettis Memorial Veterans Hospital, Loma Linda, USA
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Agolia JP, Kasper EM. Wrong-Level Spine Surgery: Introduction of a Protocol for Avoidance of This Complication. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:179-184. [PMID: 37548737 DOI: 10.1007/978-3-030-12887-6_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Wrong-level spine surgery, in which an operation is performed at a vertebral level different from the intended one, is a rare but serious complication with wide-ranging medical and legal effects. Although many protocols have been developed to prevent such a serious unfavorable event, the problem has not yet been eliminated. Research into the effectiveness of strategies to prevent wrong-level spine surgery is lacking. Herein, we describe a case of 44-year-old woman presented with neck pain and bilateral upper extremity weakness and numbness. Magnetic resonance imaging showed C5/6 and C6/7 disc herniations with spinal cord compression. The patient underwent anterior cervical discectomy and fusion; however, at the conclusion of the surgery, intraoperative radiographs showed that it was accomplished at C4/5 and C5/6-one level above the intended level. On the basis of this case and similar ones, a new protocol was developed that included implementation of a Spine Level Safety Checklist to document the reference point, the landmark, and the level of exposure that is marked on the intraoperative radiograph. Since implementation of this protocol, the incidence of wrong-level spine surgery at the senior author's institution has decreased from 4/7000 to 0/11,200. Adoption of this protocol by other centers is thus recommended to reduce the incidence of such complication.
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Affiliation(s)
| | - Ekkehard M Kasper
- DeGroote School of Medicine, McMaster University, Faculty of Health Sciences, Hamilton General Hospital, Hamilton, ON, Canada.
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Claydon MH, Laggoune JP, Wells-Quinn TA, Malham GM. Surface landmarks for anterior lumbar access: is fluoroscopy necessary? Spine J 2022; 22:411-418. [PMID: 34718174 DOI: 10.1016/j.spinee.2021.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/18/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior lumbar fusion surgery is increasing by an estimated 24% annually in the United States. There is a paucity of precise anatomic guidelines to help surgeons determine the appropriate anterior access incision site. PURPOSE The purpose of this study is to compare the available anterior surface landmarks for the L4/L5 and L5/S1 disk levels to the disk levels determined by fluoroscopy, with the goal of creating a guide for surgical incision sites in anterior lumbar access surgery. STUDY DESIGN A prospective, observational cohort study of consecutive patients undergoing anterior lumbar spinal exposure for anterior lumbar interbody fusion (ALIF), total disk replacement (TDR), or a combination of the two procedures at levels L4/L5 and/or L5/S1. PATIENT SAMPLE All patients (n=183) undergoing primary ALIF and/or TDR surgery from June 2018 to April 2021 at the study sites were assessed for inclusion, and 18 patients were excluded. The remaining 165 patients were included in the study, and a total of 208 surgical levels were exposed. OUTCOME MEASURES Mean, standard deviation, and 95% confidence interval (CI) were calculated. At each level, the distance from the symphysis pubis to the target disk level (SD distance) and the distance from the symphysis pubis to the umbilicus (SU distance) were measured, and the SD/SU ratio was calculated. Paired 2-tailed t tests were used to assess significant differences (p<.05). An R2 (coefficient of determination) test was used to assess variability of the SD distance, SU distance, and SD/SU ratio at each level. METHODS All physiologic and anatomic measures were collected prospectively by the investigators, including intraoperative measurements of SD and SU. Demographic and previous health history data were collected at the time of study enrollment. RESULTS The mean age of the 165 study participants was 48±14 years (range 18-80 years), and 97 (61%) were male. A total of 208 disk levels were exposed: 140 at L5/S1 and 68 at L4/L5. For the L5/S1, the SD ranged from 0 to 12.5 cm, with a mean of 5.2±1.9 cm (95% CI 4.88-5.52). For the L4/L5 level, the SD ranged from 6 to 15.5 cm, with a mean of 10.7±2.3 cm (95% CI 10.2-11.2). SD/SU ratios at both levels were lower in overweight (body mass index [BMI] 25-29.9) and obese (BMI 30-34.9) groups than in normal body mass index groups. There was no significant difference in SD/SU ratios between females and males at either L5/S1 (p=.39) or L4/L5 (p=.66). CONCLUSION Clinically important variability in SD distances (≥9.5 cm) was observed for both the L5/S1 and L4/L5 disk levels. SD/SU ratios provided more consistent estimates of disk location than SD distance alone, but they still displayed substantial variability. Thus, intraoperative fluoroscopy remains mandatory to accurately plan the surgical incision for anterior lumbar access surgery.
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Affiliation(s)
- Matthew H Claydon
- Epworth Hospital, 89 Bridge Road, Richmond, Vic 3121, Melbourne, Australia; The Alfred Hospital, 55 Commercial Road, Prahran, Vic 3004, Melbourne, Australia
| | - Jordan P Laggoune
- Epworth Hospital, 89 Bridge Road, Richmond, Vic 3121, Melbourne, Australia
| | | | - Gregory M Malham
- Epworth Hospital, 89 Bridge Road, Richmond, Vic 3121, Melbourne, Australia; Swinburne University of Technology, John Street, Hawthorn, Vic 3122, Melbourne, Australia.
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9
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Jackson KL, Rumley J, Griffith M, Linkous TR, Agochukwu U, DeVine J. Medical Malpractice Claims and Mitigation Strategies Following Spine Surgery. Global Spine J 2021; 11:782-791. [PMID: 32762364 PMCID: PMC8165917 DOI: 10.1177/2192568220939524] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE The aim of this narrative review is to examine trends in malpractice litigation arising from spine surgery. We also hope to detail mitigation strategies that surgeons can employ to decrease their risk of a claim. METHODS A review of the relevant literature examining the prevalence, risks, and outcomes of malpractice litigation following spine surgery was conducted using the MEDLINE and Embase databases. RESULTS Combined queries identified 1140 potentially relevant articles. After eliminating duplicate articles and screening by title and abstract, 38 articles underwent full-text review. Of these, 22 were deemed relevant to the research questions posed. Evaluation of references identified 1 additional relevant article. Spine surgery represents one of the most litigious specialties in the United States health care system. The available literature points to a consistent pattern of common allegations leading to litigation following spine surgery. While a majority of filed lawsuits end in the surgeon's favor, these cases carry high monetary and time expenditures regardless of outcome. Furthermore, the threat of a malpractice lawsuit motivates many surgeons to practice defensive medicine by utilizing unnecessary or unindicated tests and studies. CONCLUSION Through the examination of trends in malpractice claims and case outcomes, surgeons may be able to adapt practices to minimize their risk of litigation. These changes can include, but are not limited to, identification of those procedures that are most litigious and a more thorough discussion of the informed consent process to include operative and nonoperative treatments prior to all procedures. More important, however, spine surgeons can potentially serve as advocates for change.
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Affiliation(s)
- Keith L. Jackson
- Dwight David Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | | | - Matthew Griffith
- Dwight David Eisenhower Army Medical Center, Fort Gordon, GA, USA
,Matthew Griffith, Department of Orthopaedic Surgery, Dwight David Eisenhower Army Medical Center, Fort Gordon, GA 30905, USA.
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10
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Srivatsa S, Vira S, Schils J, Shook S, Gill A, Krishnaney AA. Reducing Wrong-level Spinal Surgeries Through Root Cause Analyses: A 10-year Longitudinal Analysis of a Single Tertiary Institution's Iterative Policy Improvements. Spine (Phila Pa 1976) 2021; 46:E648-E654. [PMID: 33306612 DOI: 10.1097/brs.0000000000003864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
MINI This study is a comprehensive narrative of all wrong-level spine surgeries and prevention strategies employed at our institution between 2008 and 2019, and aims to provide a roadmap for developing a rigorous prevention protocol. We systematically track root cause analyses and policy changes to determine which prevention strategies are most effective.
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Affiliation(s)
| | - Shaleen Vira
- Department of Orthopedic Surgery, UT Southwestern, Dallas, TX
| | - Jean Schils
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH
| | - Steven Shook
- Department of Neurology, Cleveland Clinic, Cleveland, OH
| | - Amanjit Gill
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH
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11
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LoPresti MA, Du RY, Yoshor D. Time-Out and Its Role in Neurosurgery. Neurosurgery 2021; 89:266-274. [PMID: 33957672 DOI: 10.1093/neuros/nyab149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 02/27/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Safety checklists have improved surgical outcomes; however, much of the literature comes from general surgery. OBJECTIVE To identify the role of time-outs in neurosurgery, understand neurosurgeons' attitudes toward time-out, and highlight areas for improvement. METHODS A cross-sectional study using a 15-item survey to evaluate how time-outs were performed across 5 hospitals affiliated with a single neurosurgery training program. RESULTS Surveys were sent to 51 neurosurgical faculty, fellows, and residents across 5 hospitals with a 72.5% response rate. At all hospitals, surgeons, anesthesiologists, registered nurses, and circulators were involved in time-outs. Although all required time-out before incision, there was no consensus regarding the precise timing of time-out, in policy or in practice. Overall, respondents believed the existing time-out was adequate for neurosurgical procedures (H1: 17, 65.4%; H2: 19, 86.4%; H3: 14, 70.0%; H4: 20, 80.0%; and H5: 18, 78.3%). Of the respondents, 97.2% believed time-out made surgery safe, 94.6% agreed that time-outs reduce the risk of wrong-side or wrong-level neurosurgery, and 17 (45.9%) saw a role for a neurosurgery-specific safety checklist. Pragmatic challenges (n = 20, 54.1%) and individual beliefs and attitudes (n = 20, 54.1%) were common barriers to implementation of standardized time-outs. CONCLUSION Multidisciplinary time-outs have become standard of care in neurosurgery. Despite proximity and overlapping personnel, there is considerable variability between hospitals in the practice of time-outs. This lack of uniformity, allowed for by flexible World Health Organization guidelines, may reflect the origins of surgical time-outs in general surgery, rather than neurosurgery, underscoring the potential for time-out optimization with neurosurgery-specific considerations.
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Affiliation(s)
- Melissa A LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Rebecca Y Du
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel Yoshor
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Garg B, Mehta N, Goyal A, Rangaswamy N, Upadhayay A. Variations in the Number of Thoracic and Lumbar Vertebrae in Patients With Adolescent Idiopathic Scoliosis: A Retrospective, Observational Study. Int J Spine Surg 2021; 15:359-367. [PMID: 33900995 DOI: 10.14444/8047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Abnormal anatomy is a contributory factor to wrong-level surgery. Variations in the number of vertebrae in populations from different races and geographical regions have been described. A ∼10% prevalence of variations in number of thoracic and lumbar vertebrae in adolescent idiopathic scoliosis (AIS) patients has been previously reported. The objectives of present study were (i) to find out the prevalence of variations in the number of thoracic and lumbar vertebrae and the presence of lumbosacral transitional vertebrae (LSTV) in Indian AIS patients and (ii) to correlate these variations with gender and type of curve. METHODS Hospital records and imaging of 198 AIS patients were reviewed retrospectively. A standardized numbering strategy was used to identify the number of thoracic vertebrae, number of lumbar vertebrae, and presence of LSTV. Patients' gender and curve type were correlated with the presence of an abnormal number of thoracic or lumbar vertebrae. Radiology reports and operation notes were reviewed to find out instances when the radiologist or surgeon had identified an abnormal number of vertebrae. RESULTS Forty patients (20.2%) with abnormally numbered thoracic or lumbar vertebrae were identified. Twenty patients (10.1%) had abnormally numbered thoracic vertebrae, and 33 patients (16.7%) had abnormally numbered lumbar vertebrae. The prevalence of LSTV was 18.2%. Presence of variations did not correlate with gender or curve type. Radiology reports identified 2/40 patients with variations, whereas operation notes showed 4/40 patients had been correctly identified to have abnormally numbered vertebrae. CONCLUSIONS There is high prevalence of variation in the number of thoracic or lumbar vertebrae in AIS patients, with most of those missed being identified by radiologists or surgeons. The patient's preoperative imaging must be scrutinized to identify these patients and take the variation into account to avoid wrong selection of fusion levels. LEVEL OF EVIDENCE 3. CLINICAL RELEVANCE Text. The study raises awareness about possibility of wrong selection in fusion levels due to anatomical variations in surgery for AIS.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Archit Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Namith Rangaswamy
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Arpan Upadhayay
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Medress ZA, Jin MC, Feng A, Varshneya K, Veeravagu A. Medical malpractice in spine surgery: a review. Neurosurg Focus 2020; 49:E16. [DOI: 10.3171/2020.8.focus20602] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/20/2020] [Indexed: 11/06/2022]
Abstract
Medical malpractice is an important but often underappreciated topic within neurosurgery, particularly for surgeons in the early phases of practice. The practice of spinal neurosurgery involves substantial risk for litigation, as both the natural history of the conditions being treated and the operations being performed almost always carry the risk of permanent damage to the spinal cord or nerve roots, a cardiopulmonary event, death, or other dire outcomes. In this review, the authors discuss important topics related to medical malpractice in spine surgery, including tort reform, trends and frequency of litigation claims in spine surgery, wrong-level and wrong-site surgery, catastrophic outcomes including spinal cord injury and death, and ethical considerations.
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Castle-Kirszbaum M, Maingard J, Goldschlager T, Chandra RV. Preoperative coil localization for spinal surgery: technical note. J Neurosurg Spine 2020; 32:483-487. [PMID: 31731276 DOI: 10.3171/2019.8.spine19762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
Intraoperative localization in spinal surgery is essential to facilitate the best surgical outcome and to avoid wrong-site surgery. Intraoperative fluoroscopy is generally adequate, but anatomical variation, body habitus, and the inherent difficulties of fluoroscopy at certain levels may lead the surgeon astray. Here, the authors present their technique for preoperative localization that relies solely on fixed anatomical landmarks using CT-guided, percutaneously placed radiopaque markers. In the outpatient setting, low-dose CT scanning of the neuraxis is performed to identify fixed landmarks and, under local anesthesia and CT guidance, a pushable microcoil is inserted through a Chiba needle into the periosteum of the pedicle at the level of interest. The patient returns home with no precautions while the coil is in situ, and then the patient returns sometime later for surgery. Intraoperatively, typically a single lateral radiograph is required to visualize the coil and the level. Preoperative placement of radiopaque markers at the level of interest is an effective tool for avoiding wrong-site surgery, especially in circumstances in which fluoroscopy may be troublesome. The authors' method is accurate, effective, and expeditious and can be performed easily in the outpatient setting.
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Affiliation(s)
| | - Julian Maingard
- 2Neurointerventional Radiology Unit, Monash Imaging, Monash Health, Melbourne; and
| | - Tony Goldschlager
- 1Department of Neurosurgery and
- 3Department of Surgery, Monash University, Melbourne, Australia
| | - Ronil V Chandra
- 2Neurointerventional Radiology Unit, Monash Imaging, Monash Health, Melbourne; and
- 3Department of Surgery, Monash University, Melbourne, Australia
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Derman PB, Phillips FM. Complication avoidance in minimally invasive spinal surgery. JOURNAL OF SPINE SURGERY 2019; 5:S57-S67. [PMID: 31380493 DOI: 10.21037/jss.2019.04.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive techniques in spinal surgery allow surgeons to perform operations with less of the approach-related morbidity inherent to traditional open procedures. Yet these muscle-sparing procedures come with a unique set of risks that stem from the novel approaches, limited exposure, and/or a restricted working corridor that they employ. The literature suggests that these operations can be performed without an increased rate of complication once the associated learning curve has been surmounted, suggesting that knowledge of and experience with the nuances of these procedures are essential for patient safety. The present article describes the complications specific to a variety of minimally invasive spinal surgeries and provides guidance on how to avoid them.
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Affiliation(s)
| | - Frank M Phillips
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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A reproducible and reliable localization technique for lumbar spine surgery that minimizes unintended-level exposure and wrong-level surgery. Spine J 2019; 19:773-780. [PMID: 30529787 DOI: 10.1016/j.spinee.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/02/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Exposure of unintended levels (defined as a spinal segment outside the intended surgical levels) is unnecessary and potentially adds to operative time and patient morbidity. Wrong-level surgery (defined as decompression, instrumentation, or fusion of a spinal segment not part of the intended surgical procedure) clearly adds to morbidity as well as putting the surgeon at medicolegal risk. PURPOSE To describe a localization technique for posterior lumbar spine surgery to minimize both unintended-level exposure and wrong-level surgery. STUDY DESIGN Consecutive case series. PATIENT SAMPLE One thousand nine hundred and eighty-six consecutive posterior lumbar operations performed from January 2010 to January 2017 using this technique were reviewed. OUTCOME MEASURES The primary outcome measure was the incidence of unintended-level exposure and wrong-level surgery. METHODS This localization technique was consistently used for determination of skin incision, soft tissue dissection, and identification of spinal levels for all patients undergoing posterior lumbar surgery during the time interval noted. Two spinal needles are inserted under sterile technique 3cm lateral to the midline before incision at the approximate cranial and caudal aspects of the anticipated incision based on external landmarks. A cross-table lateral X-ray before incision is obtained and the actual incision is adjusted based on the location of the spinal needles. Once dissection is carried down to the facet capsules, spinal needles are then placed in adjacent facets, and a second cross-table lateral film is obtained to confirm appropriate levels. A retrospective review of all posterior lumbar cases was performed to determine the incidence of unintended-level exposure and wrong-level surgery using this technique. RESULTS There were no wrong-level surgeries during this time period. There were six (0.30%) cases of unintended-level exposure. CONCLUSIONS The technique described provides surgeons with a reliable, accurate, and easily reproducible method for localizing surgical levels during posterior lumbar spine surgery while minimizing exposure of uninvolved areas. This technique offers distinct advantages over previously proposed protocols and may lead to a widely accepted system for intraoperative spinal level identification.
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Vitale M, Minkara A, Matsumoto H, Albert T, Anderson R, Angevine P, Buckland A, Cho S, Cunningham M, Errico T, Fischer C, Kim HJ, Lehman R, Lonner B, Passias P, Protopsaltis T, Schwab F, Lenke L. Building Consensus: Development of Best Practice Guidelines on Wrong Level Surgery in Spinal Deformity. Spine Deform 2018; 6:121-129. [PMID: 29413733 DOI: 10.1016/j.jspd.2017.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Abstract
STUDY DESIGN Consensus-building using the Delphi and nominal group technique. OBJECTIVE To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. SUMMARY OF BACKGROUND DATA Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. METHODS The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. RESULTS Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. CONCLUSION We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Michael Vitale
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Anas Minkara
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Hiroko Matsumoto
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA.
| | - Todd Albert
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Richard Anderson
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Peter Angevine
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Aaron Buckland
- New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003, USA
| | - Samuel Cho
- Mount Sinai, 5 E 98th St, 4th Floor, New York, NY 10029, USA
| | | | - Thomas Errico
- New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003, USA
| | - Charla Fischer
- New York-Presbyterian The Allen Hospital, 5141 Broadway, New York, NY 10034, USA
| | - Han Jo Kim
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Ronald Lehman
- New York-Presbyterian The Allen Hospital, 5141 Broadway, New York, NY 10034, USA
| | - Baron Lonner
- Scoliosis and Spine Associates, 820 2nd Ave, New York, NY 10017, USA
| | - Peter Passias
- New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003, USA
| | | | - Frank Schwab
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Lawrence Lenke
- New York-Presbyterian The Allen Hospital, 5141 Broadway, New York, NY 10034, USA
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Daniels AH, Ruttiman R, Eltorai AEM, DePasse JM, Brea BA, Palumbo MA. Malpractice litigation following spine surgery. J Neurosurg Spine 2017; 27:470-475. [DOI: 10.3171/2016.11.spine16646] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAdverse events related to spine surgery sometimes lead to litigation. Few studies have evaluated the association between spine surgical complications and medical malpractice proceedings, outcomes, and awards. The aim of this study was to identify the most frequent causes of alleged malpractice in spine surgery and to gain insight into patient demographic and clinical characteristics associated with medical negligence litigation.METHODSA search for “spine surgery” spanning February 1988 to May 2015 was conducted utilizing the medicolegal research service VerdictSearch (ALM Media Properties, LLC). Demographic data for the plaintiff and defendant in addition to clinical data for the procedure and legal outcomes were examined. Spinal cord injury, anoxic/hypoxic brain injury, and death were classified as catastrophic complications; all other complications were classified as noncatastrophic. Both chi-square and t-tests were used to evaluate the effect of these variables on case outcomes and awards granted.RESULTSA total of 569 legal cases were examined; 335 cases were excluded due to irrelevance or insufficient information. Of the 234 cases included in this investigation, 54.2% (127 cases) resulted in a defendant ruling, 26.1% (61) in a plaintiff ruling, and 19.6% (46) in a settlement. The awards granted for plaintiff rulings ranged from $134,000 to $38,323,196 (mean $4,045,205 ± $6,804,647). Awards for settlements ranged from $125,000 to $9,000,000 (mean $1,930,278 ± $2,113,593), which was significantly less than plaintiff rulings (p = 0.022). Compared with cases without a delay in diagnosis of the complication, the cases with a diagnostic delay were more likely to result in a plaintiff verdict or settlement (42.9% vs 72.7%, p = 0.007) than a defense verdict, and were more likely to settle out of court (17.5% vs 40.9%, p = 0.008). Similarly, compared with cases without a delay in treatment of the complication, those with a therapeutic delay were more likely to result in a plaintiff verdict or settlement (43.7% vs 68.4%, p = 0.03) than a defense verdict, and were more likely to settle out of court (18.1% vs 36.8%, p = 0.04). Overall, 28% of cases (66/234) involved catastrophic complications. Physicians were more likely to lose cases (plaintiff verdict or settlement) with catastrophic complications (66.7% vs 37.5%, p < 0.001). In cases with a plaintiff ruling, catastrophic complications resulted in significantly larger mean awards than noncatastrophic complications ($6.1M vs $2.9M, p = 0.04). The medical specialty of the provider and the age or sex of the patient were not associated with the case outcome or award granted (p > 0.05). The average time to a decision for defendant verdicts was 5.1 years; for plaintiff rulings, 5.0 years; and for settlements, 3.4 years.CONCLUSIONSDelays in the diagnosis and the treatment of a surgical complication predict legal case outcomes favoring the plaintiff. Catastrophic complications are linked to large sums awarded to the plaintiff and are predictive of rulings against the physician. For physician defendants, the costs of settlements are significantly less than those of losing in court. Although this study provides potentially valuable data from a large series of postoperative litigation cases, it may not provide a true representation of all jurisdictions, each of which has variable malpractice laws and medicolegal environments.
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Affiliation(s)
- Alan H. Daniels
- 1Brown University, Providence, Rhode Island
- 4Division of Spine Surgery,
| | - Roy Ruttiman
- 1Brown University, Providence, Rhode Island
- 2Alpert Medical School of
| | | | - J. Mason DePasse
- 1Brown University, Providence, Rhode Island
- 3Department of Orthopaedic Surgery, and
| | | | - Mark A. Palumbo
- 1Brown University, Providence, Rhode Island
- 4Division of Spine Surgery,
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Abstract
STUDY DESIGN Prospective chart review. OBJECTIVE It is well-known that radiation exposure during minimally invasive spine procedures can be substantial. Less interest has focused on setup radiation exposure before incision, including preoperative images used for surgical approach. The present study seeks to better quantify the significance of setup radiation in the total radiation exposure of minimally invasive spine surgery. SUMMARY OF BACKGROUND DATA Radiographic localization is necessary in minimally invasive spine procedures to visualize anatomy, but increased radiation exposure is associated with health risks. Preoperative imaging for anatomical localization has not been previously analyzed as an appreciable source of radiation. METHODS From an institutional review board-approved database of more than 1100 procedures, the minimally invasive spine cases with recorded set-up radiation were extracted. The total radiation, set-up radiation, and procedure type data were evaluated. Statistics were generated using a chi-squared analysis. RESULTS Set-up and total radiation data were collected for 270 spine surgeries performed by four surgeons at two locations. There were 30 thoracic and 240 thoracolumbar/lumbar cases; 78 anterior and 192 posterior cases. Average total radiation (set-up and intraoperative) was 8.04 rad, and average setup radiation was 1.90 rad (28%, std 2.97 rad) across all cases. On average for the thoracolumbar/lumbar cases, set-up radiation accounted for almost 25% of total radiation with 1.76 rad from setup out of 8.16 rad total. Thoracic-only cases often necessitated even more images for localization, generating an average set-up/total percentage of 52%. Across all procedures, set-up radiation significantly increased the total radiation exposure because it accounted for more than 25% of the total procedure. CONCLUSION Radiation exposure during preoperative localization can be substantial. Operating room personnel should recognize the high percentage of radiation that occurs during set-up, and merit should be given to techniques and technologies that can limit unnecessary radiation exposure during this portion of the procedure. LEVEL OF EVIDENCE 2.
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Reaungamornrat S, De Silva T, Uneri A, Goerres J, Jacobson M, Ketcha M, Vogt S, Kleinszig G, Khanna AJ, Wolinsky JP, Prince JL, Siewerdsen JH. Performance evaluation of MIND demons deformable registration of MR and CT images in spinal interventions. Phys Med Biol 2016; 61:8276-8297. [PMID: 27811396 DOI: 10.1088/0031-9155/61/23/8276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Accurate intraoperative localization of target anatomy and adjacent nervous and vascular tissue is essential to safe, effective surgery, and multimodality deformable registration can be used to identify such anatomy by fusing preoperative CT or MR images with intraoperative images. A deformable image registration method has been developed to estimate viscoelastic diffeomorphisms between preoperative MR and intraoperative CT using modality-independent neighborhood descriptors (MIND) and a Huber metric for robust registration. The method, called MIND Demons, optimizes a constrained symmetric energy functional incorporating priors on smoothness, geodesics, and invertibility by alternating between Gauss-Newton optimization and Tikhonov regularization in a multiresolution scheme. Registration performance was evaluated for the MIND Demons method with a symmetric energy formulation in comparison to an asymmetric form, and sensitivity to anisotropic MR voxel-size was analyzed in phantom experiments emulating image-guided spine-surgery in comparison to a free-form deformation (FFD) method using local mutual information (LMI). Performance was validated in a clinical study involving 15 patients undergoing intervention of the cervical, thoracic, and lumbar spine. The target registration error (TRE) for the symmetric MIND Demons formulation (1.3 ± 0.8 mm (median ± interquartile)) outperformed the asymmetric form (3.6 ± 4.4 mm). The method demonstrated fairly minor sensitivity to anisotropic MR voxel size, with median TRE ranging 1.3-2.9 mm for MR slice thickness ranging 0.9-9.9 mm, compared to TRE = 3.2-4.1 mm for LMI FFD over the same range. Evaluation in clinical data demonstrated sub-voxel TRE (<2 mm) in all fifteen cases with realistic deformations that preserved topology with sub-voxel invertibility (0.001 mm) and positive-determinant spatial Jacobians. The approach therefore appears robust against realistic anisotropic resolution characteristics in MR and yields registration accuracy suitable to application in image-guided spine-surgery.
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Affiliation(s)
- S Reaungamornrat
- Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA
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Affiliation(s)
- Arthur Atchabahian
- Department of Anesthesiology, NYU School of Medicine, New York, New York,
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Mukerji N, Seetharam Manjunath Prasad K, Tizzard S, Aziz F, Varma A, Sinar E, Nath F, Strachan R, Kane P, Williamson S. Wrong-level spinal surgery - 'never' again? Br J Neurosurg 2016; 30:200-1. [PMID: 26966921 DOI: 10.3109/02688697.2016.1155694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Nitin Mukerji
- a Department of Neurosurgery , James Cook University Hospital , Middlesbrough , UK
| | | | - Simon Tizzard
- a Department of Neurosurgery , James Cook University Hospital , Middlesbrough , UK
| | - Farooq Aziz
- a Department of Neurosurgery , James Cook University Hospital , Middlesbrough , UK
| | - Anil Varma
- a Department of Neurosurgery , James Cook University Hospital , Middlesbrough , UK
| | - Ernest Sinar
- a Department of Neurosurgery , James Cook University Hospital , Middlesbrough , UK
| | - Fred Nath
- a Department of Neurosurgery , James Cook University Hospital , Middlesbrough , UK
| | - Roger Strachan
- a Department of Neurosurgery , James Cook University Hospital , Middlesbrough , UK
| | - Philip Kane
- a Department of Neurosurgery , James Cook University Hospital , Middlesbrough , UK
| | - Sean Williamson
- b Department of Anaesthesia , James Cook University Hospital , Middlesbrough , UK ;,c Directorate of Quality Assurance , James Cook University Hospital , Middlesbrough , UK
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Missios S, Bekelis K. Spine surgery and malpractice liability in the United States. Spine J 2015; 15:1602-8. [PMID: 25840399 DOI: 10.1016/j.spinee.2015.03.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 02/09/2015] [Accepted: 03/20/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The correlation of negative outcomes with aggressiveness of malpractice liability has been questioned in the literature. PURPOSE The aim of this study was to investigate the association of malpractice liability with unfavorable outcomes and hospitalization charges in spine surgery. STUDY DESIGN/SETTING This was a retrospective cohort study. PATIENT SAMPLE The sample included a total of 709,951 patients undergoing spine surgery who were registered in the Nationwide Inpatient Sample (NIS) database from 2005 to 2010. OUTCOME MEASURES The outcome measures were state-level mortality, length of stay (LOS), and hospitalization charges after spinal surgery. METHODS We performed a retrospective cohort study involving patients who underwent spine surgery from 2005 to 2010 and were registered in NIS. We used data from the National Practitioner Data Bank from 2005 to 2010 to create measures of volume and size of malpractice claim payments. Their association of the latter with the outcome measures was investigated. RESULTS During the study period, there were 707,951 patients (mean age, 54.4 years, with 49.7% females) who underwent spine surgery and were registered in NIS. In a multivariable regression model, higher number of claims per 100 physicians in a state was associated with increased hospitalization charges (β=0.14; 95% confidence interval [CI], 0.13-0.14) and LOS (β=0.041; 95% CI, 0.036-0.047). On the contrary, there was no association with mortality (odds ratio [OR], 0.99; 95% CI, 0.87-1.12). Larger magnitude of awarded claims was associated with increased hospitalization charges (β=0.08; 95% CI, 0.075-0.09) and LOS (β=0.02; 95% CI, 0.016-0.031). On the contrary, there was no association with mortality (OR, 0.95; 95% CI, 0.82-1.11). CONCLUSIONS In the present national study, aggressive malpractice environment was not correlated with mortality but was associated with higher hospitalization charges after spine surgery. Further research is needed to identify ways to regulate the malpractice system to address these disparities.
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Affiliation(s)
- Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, 1541 Kings Hwy, Shreveport, LA 71103, USA
| | - Kimon Bekelis
- Department of Surgery, Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH 03756, USA.
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Ziewacz JE, McGirt MJ, Chewning SJ. Adverse events in neurosurgery and their relationship to quality improvement. Neurosurg Clin N Am 2014; 26:157-65, vii. [PMID: 25771271 DOI: 10.1016/j.nec.2014.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Adverse events are common in neurosurgery. Their reporting is inconsistent and widely variable due to nonuniform definitions, data collection mechanisms, and retrospective data collection. Historically, neurosurgery has lagged behind general and cardiac surgical fields in the creation of multi-institutional prospective databases allowing for benchmarking and accurate adverse event/outcomes measurement, the bedrock of evidence used to guide quality improvement initiatives. The National Neurosurgery Quality and Outcomes Database has begun to address this issue by collecting prospective, multi-institutional outcomes data in neurosurgical patients. Once reliable outcomes exist, various targeted quality improvement strategies may be used to reduce adverse events and improve outcomes.
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Affiliation(s)
- John E Ziewacz
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Avenue, Charlotte, NC 28204, USA.
| | - Matthew J McGirt
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Avenue, Charlotte, NC 28204, USA
| | - Samuel J Chewning
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Avenue, Charlotte, NC 28204, USA
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Spencer HT, Gold ME, Hresko MT. Abnormal rib count in scoliosis surgery: impact on the reporting of spinal fusion levels. J Child Orthop 2014; 8:497-503. [PMID: 25370702 PMCID: PMC4252269 DOI: 10.1007/s11832-014-0623-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 10/20/2014] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Variation in rib numbering has been noted in adolescent idiopathic scoliosis (AIS), but its effect on the reporting of fusion levels has not been studied. We hypothesized that vertebral numbering variations can lead to differing documentation of fusion levels. METHODS We examined the radiographs of 161 surgical AIS patients and 179 control patients without scoliosis. For AIS patients, the operative report of fusion levels was compared to conventional vertebral labeling from the first thoracic level and proceeding caudal. We defined normal counts as 12 thoracic (rib-bearing) and five lumbar (non-rib-bearing) vertebrae. We compared our counts with data from 181 anatomic specimens. RESULTS Among AIS patients, 22 (14 %) had an abnormal number of ribs and 29 (18 %) had either abnormal rib or lumbar count. In 12/29 (41 %) patients, the operative report differed from conventional labeling by one level, versus 3/132 (2 %) patients with normal numbering (p < 0.001). However, there were no cases seen of wrong fusion levels based on curve pattern. Among controls, 11 % had abnormal rib count (p = 0.41) compared to the rate in AIS. Anatomic specimen data did not differ in abnormal rib count (p = 1.0) or thoracolumbar pattern (p = 0.59). CONCLUSIONS The rate of numerical variations in the thoracolumbar vertebrae of AIS patients is equivalent to that in the general population. When variations in rib count are present, differences in numbering levels can occur. In the treatment of scoliosis, no wrong fusion levels were noted. However, for both scoliosis patients and the general population, we suggest adherence to conventional labeling to enhance clarity.
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Affiliation(s)
- Hillard T Spencer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Hunnewell 2, Boston, MA, 02115, USA,
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Turel MK, Rajshekhar V. Magnetic resonance imaging localization with cod liver oil capsules for the minimally invasive approach to small intradural extramedullary tumors of the thoracolumbar spine. J Neurosurg Spine 2014; 21:882-5. [DOI: 10.3171/2014.9.spine14199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Accurate intraoperative localization of small intradural extramedullary thoracolumbar (T-1 to L-3 level) spinal cord tumors is vital when minimally invasive techniques, such as hemilaminectomy, are used to excise these lesions. In this study, the authors describe a simple and effective method of preoperative MRI localization of small intradural extramedullary tumors using cod liver oil capsules.
Methods
Thirty-five patients with intradural tumors underwent preoperative MRI localization the evening prior to surgery. Patients were positioned prone in the MRI gantry, mimicking the intraoperative position. Nine capsules were placed in 3 rows to cover the lesion. This localization was used to guide the level for a minimally invasive approach using a hemilaminectomy to excise these tumors.
Results
The mean patient age was 51.5 ± 14.3 years, and the mean body mass index was 24.1 ± 3.5 kg/m2. Twenty-two tumors involved the thoracic spine, and 13 involved the upper lumbar spine from L-1 to L-3. The mean tumor size was 2.2 ± 1.0 cm. Localization was accurate in 34 patients (97.1%).
Conclusions
Accurate localization with the described method is quick, safe, cost-effective, and noninvasive with no exposure to radiation. It also reduces operating time by eliminating the need for intraoperative fluoroscopy.
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Radiograms Obtained during Anterior Cervical Decompression and Fusion Can Mislead Surgeons into Performing Surgery at the Wrong Level. Case Rep Orthop 2014; 2014:398457. [PMID: 25386376 PMCID: PMC4216671 DOI: 10.1155/2014/398457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/20/2014] [Accepted: 10/06/2014] [Indexed: 11/17/2022] Open
Abstract
A 68-year-old woman who suffered from C5 nerve palsy because of a C4-5 disc herniation was referred to our hospital. We conducted anterior cervical decompression and fusion (ACDF) at the C4-5 level. An intraoperative radiogram obtained after exposure of the vertebrae showed that the level at which we were going to perform surgery was exactly at the C4-5 level. After bone grafting and temporary plating, another radiogram was obtained to verify the correct placement of the plate and screws, and it appeared to show that the plate bridged the C5 and C6 vertebrae at the incorrect level. The surgeon was astonished and was about to begin decompression of the upper level. However, carefully double-checking the level with a C-arm image intensifier before additional decompression verified that the surgery was conducted correctly at C4-5. Cautiously double-checking the level of surgery with a C-arm image intensifier is recommended when intraoperative radiograms suggest surgery at the wrong level.
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Hamdan A, Strachan RD, Nath F, Coulter IC. Counting the cost of negligence in neurosurgery: Lessons to be learned from 10 years of claims in the NHS. Br J Neurosurg 2014; 29:169-77. [DOI: 10.3109/02688697.2014.971709] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C, Mehrotra S. Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res 2014; 193:88-94. [PMID: 25277361 DOI: 10.1016/j.jss.2014.08.062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 08/15/2014] [Accepted: 08/28/2014] [Indexed: 11/30/2022]
Abstract
Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.
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Affiliation(s)
- Zachary A Abecassis
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Lisa M McElroy
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ronak M Patel
- Division of Sports Medicine, Illinois Bone and Joint Institute, LLC, Morton Grove, Illinois
| | - Rebeca Khorzad
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Charles Carroll
- Department of Orthopaedic Surgery, NOI NorthShore Orthopedics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sanjay Mehrotra
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Ladak A, Spinner RJ. Redefining “Wrong Site Surgery” and Refining the Surgical Pause and Checklist: Taking Surgical Safety to Another Level. World Neurosurg 2014; 81:e33-5. [DOI: 10.1016/j.wneu.2013.02.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 02/12/2013] [Indexed: 11/16/2022]
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Fargen KM, Friedman WA. The science of medical decision making: neurosurgery, errors, and personal cognitive strategies for improving quality of care. World Neurosurg 2014; 82:e21-9. [PMID: 24650488 DOI: 10.1016/j.wneu.2014.03.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 03/12/2014] [Indexed: 01/21/2023]
Abstract
During the last 2 decades, there has been a shift in the U.S. health care system towards improving the quality of health care provided by enhancing patient safety and reducing medical errors. Unfortunately, surgical complications, patient harm events, and malpractice claims remain common in the field of neurosurgery. Many of these events are potentially avoidable. There are an increasing number of publications in the medical literature in which authors address cognitive errors in diagnosis and treatment and strategies for reducing such errors, but these are for the most part absent in the neurosurgical literature. The purpose of this article is to highlight the complexities of medical decision making to a neurosurgical audience, with the hope of providing insight into the biases that lead us towards error and strategies to overcome our innate cognitive deficiencies. To accomplish this goal, we review the current literature on medical errors and just culture, explain the dual process theory of cognition, identify common cognitive errors affecting neurosurgeons in practice, review cognitive debiasing strategies, and finally provide simple methods that can be easily assimilated into neurosurgical practice to improve clinical decision making.
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Affiliation(s)
- Kyle M Fargen
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
| | - William A Friedman
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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