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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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Naqvi AZ, Magill H, Anjarwalla N. Intraoperative practices to prevent wrong-level spine surgery: a survey among 105 spine surgeons in the United Kingdom. Patient Saf Surg 2022; 16:6. [PMID: 35081968 PMCID: PMC8790839 DOI: 10.1186/s13037-021-00310-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/29/2021] [Indexed: 11/21/2022] Open
Abstract
Background Current literature suggests that wrong-level spine surgery is relatively common with far-reaching consequences. This study aims to assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for correct level verification. Methods To assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for level verification. The authors hypothesise the absence of a standardised technique used across spine surgeons in the UK. Practices amongst respondents will be ascertained via an electronic questionnaire designed to evaluate current practices of spinal surgeons whom are members of the British Association of Spinal Surgeons (BASS). The study data will include key information such as; the level of surgical experience, specific techniques used to perform level checks for each procedure and prior involvement with wrong-level spine surgery. Responses were collected over the period of 1 month with a reminder sent 2 weeks prior to closure of the survey. The data were collated and descriptive analyses performed on multiple-choice question answers and common themes established from free text answers. Results A total of 27% (n = 105/383) members responded. The vast majority had greater than 10 years’ experience. Intraoperative practices varied greatly with varying practices present for cervical, thoracic and lumbar level surgery. Only 38% (n = 40) of respondents re-checked the level intra-operatively, prior to instrumentation. Of the respondents 47.5% (n = 29/61) of surgeons had been involved in wrong level spinal surgery. Conclusion This study highlights the varying practices amongst spinal surgeons and suggests root cause for wrong-level spine surgery; where the level identified pre-incision was subsequently not the level exposed. We describe a novel safety-check adopted at our institute using concepts and lessons learnt from the WHO Checklist.
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Prod'homme M, Grasset D, Lecocq M, Boscherini D. Intraoperative disc level marking with needle: a technical note and prospective study on 30 patients. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:190-196. [PMID: 34296031 PMCID: PMC8261559 DOI: 10.21037/jss-20-671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/18/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Wrong-level surgery is a rare but unresolved issue in spine surgery. Some proposed protocols with high success rates, but it remains a risk with potential complications for the patient. Surgical navigation offers more accurate surgery, without additional irradiation related to the imaging device, in order to optimize the surgical guidance. METHODS We describe our institutional technique with a needle placed under fluoroscopy at 3 cm from the incision line at the disc level to be operated, in order to guide the surgical approach; and we report a prospective evaluation of all patients during a six-month period operated by microdiscectomy for symptomatic lumbar discus hernia, whose hernia level was landmarked with this technique. We collected demographic, clinical-such as visual analog scale (VAS) of pain and Oswestry disability index (ODI) scores-operative and irradiation data for effective dose calculation. RESULTS Thirty patients were included in the study. No wrong-level procedure was performed. Mean time for landmarking was 2.22 [1-5] minutes. Average operative time was 54.5 [30-150] minutes. The effective dose related to the imaging device use was 0.032 (0.007-0.092) mSv. The effective dose was also correlated to body mass index and disc level (P=0.05). The operative duration, complication rate and postoperative VAS and ODI scores were similar to the current literature. CONCLUSIONS We advocate the use of percutaneous needle guidance, avoiding wrong-level microdiscectomy and helping the surgeon as a "navigation-like" device with minimal additional irradiation for the patient.
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Affiliation(s)
- Marc Prod'homme
- Clinic La Source, Neuro Orthopedic Center, Lausanne, Switzerland
| | - Didier Grasset
- Clinic La Source, Neuro Orthopedic Center, Lausanne, Switzerland
| | - Mélissa Lecocq
- Clinic La Source, Neuro Orthopedic Center, Lausanne, Switzerland
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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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Abstract
Quality Improvement (QI) throughout health care in the United States continues to be of growing importance to both patients and providers. Leaders in health care including physicians, nurses, hospital administrators, and payors are all responsible for ensuring the continuation and growth of QI initiatives. This article will discuss various ways that healthcare leaders, with specific regard to orthopedic surgery, have utilized QI measures to provide better, more efficient, care to patients.
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Abstract
STUDY DESIGN Cadaver training lab. OBJECTIVE To determine if a technical cadaver skills training lab for spinal surgery increases resident confidence, satisfaction in training, and perception of operating room safety. SUMMARY OF BACKGROUND DATA Resident training is an important topic in the setting of work hour reform. The use of supplemental materials such as videos, sawbones, and simulators may become important to adequately train orthopedic residents. At present, there are no established curricula for training orthopedic surgery residents on anatomy and common procedures encountered during a spinal surgery rotation. METHODS Residents were assembled into teams of a PGY-5 and PGY-2 and/or PGY-1 to perform dissection and procedures on 5 fresh-frozen spine cadavers. With attending and spine fellow supervision, residents performed anterior cervical, posterior cervical, and posterior thoracolumbar surgical exposure, decompression, and fusion procedures in the operating room using surgical tools and instrumentation. Residents were then queried about their confidence levels, satisfaction in training, and perception of safety using a Likert scale (0-10). Strong agreement (scores ≥8) and strong disagreement (scores ≤3) and correlations were evaluated. RESULTS Seventeen residents completed the training program (7 PGY-1s, 2 PGY-2s, and 8 PGY-5s). After the training, the majority of residents strongly agreed that they had an increased confidence of their own abilities (59%). A significant majority (65%) of residents strongly agreed that they were satisfied with the benefits provided by the training program. Compared with other methods of education, residents strongly agreed that the training was more helpful than textbook chapters (94%), sawbones (94%), web-based training (94%), or a virtual-based (completely electronic) training (94%). After the training, residents strongly agreed that the training improved feelings of preparation (47%), safety (41%), and ability to prevent intraoperative errors (41%). The vast majority of residents strongly agreed "Before performing surgery on me, I would want a resident to perform this cadaveric training" (88%). CONCLUSIONS These results demonstrate that team-based, cadaveric training with adequate attending supervision, before onset of a spine surgical rotation, may lead to high resident confidence, satisfaction in training, and perception of patient safety.
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Abstract
STUDY DESIGN A review of accident and incident reports. OBJECTIVE To analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery. SUMMARY OF BACKGROUND DATA In our institution, a clinical error that potentially results in an adverse event is usually submitted as an incident or accident report through a web database, to ensure anonymous and blame-free reporting. All reports are analyzed by a medical safety management group. These reports contain valuable data for management of medical safety, but there have been no studies evaluating such data for spine surgery. METHODS A total of 320 incidents and accidents that occurred perioperatively in 172 of 415 spine surgeries were included in the study. Incidents were defined as events that were "problematic, but with no damage to the patient," and accidents as events "with damage to the patient." The details of these events were analyzed. RESULTS There were 278 incidents in 137 surgeries and 42 accidents in 35 surgeries, giving prevalence of 33% (137/415) and 8% (35/415), respectively. The proportion of accidents among all events was significantly higher for doctors than non-doctors [68.0% (17/25) vs. 8.5% (25/295), P < 0.01] and in the operating room compared with outside the operating room [40.5% (15/37) vs. 9.5% (27/283), P < 0.01]. There was no significant difference in years of experience among personnel involved in all events. The major types of events were medication-related, line and tube problems, and falls and slips. Accidents also occurred because of a long-term prone position, with complications such as laryngeal edema, ulnar nerve palsy, and tooth damage. CONCLUSION Surgery and procedures in the operating room always have a risk of complications. Therefore, a particular effort is needed to establish safe management of this environment and to provide advice on risk to the doctor and medical care team. LEVEL OF EVIDENCE 4.
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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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Abstract
STUDY DESIGN Retrospective national database analysis. OBJECTIVE A national population-based database was queried to investigate the incidence and perioperative outcomes associated with sentinel events in lumbar spine surgery. SUMMARY OF BACKGROUND DATA Sentinel events in lumbar spine surgery can have significant medical, social, economic, and legal implications. The incidence and perioperative outcomes associated with these events have not been well characterized. METHODS Data from the Nationwide Inpatient Sample was queried from 2002 to 2011. Patients who underwent lumbar spinal surgery were identified. Sentinel events including bowel or peritoneal injury, vascular injury, nerve injury, retention of foreign objects, and wrong-site surgery were identified. Patient demographics, comorbidities (Charlson Comorbidity Index), length of stay, total costs, and perioperative outcomes were assessed. The risk for mortality associated with each sentinel event was calculated using a 95% confidence interval. Statistical analysis was performed with SPSS version 20 and a P value of 0.001 or less denoted significance. RESULTS A total of 543,146 lumbar spine surgical procedures were recorded from 2002 to 2011, of which 414 (0.8 per 1000 cases) incurred sentinel events. Wrong-site surgical procedures were the most common sentinel events with an incidence of 0.3 per 1000 cases. The incidences for bowel or peritoneal injury, vascular injury, nerve injury, and retention of foreign objects, were 0.06, 0.2, 0.2, and 0.1 per 1000 cases, respectively. There were no significant differences in the mean age (55.9 vs. 56.0, P = 0.911) or comorbidity burden (2.58 vs. 2.63, P = 0.553) between the 2 cohorts. The sentinel event cohort incurred a longer hospitalization, greater costs, and a greater incidence of in-hospital complications, and mortality. Patients with a bowel or peritoneal injury, vascular injury, and wrong-site surgery demonstrated a greater risk of mortality relative to unaffected patients. CONCLUSION This Nationwide Inpatient Sample analysis demonstrates that sentinel events are associated with a significant increase in hospital resource utilization and worsened postoperative outcomes including death. This study demonstrates the financial and medical burden associated with sentinel events in lumbar spine surgery. LEVEL OF EVIDENCE 4.
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Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE A national population-based database was queried to investigate the incidence of sentinel events in cervical spine surgery as well as the associated perioperative outcomes. SUMMARY OF BACKGROUND DATA Sentinel events in cervical spine surgery are potentially catastrophic complications. The incidence and perioperative outcomes associated with sentinel events in cervical spine surgery have not been well characterized. METHODS The Nationwide Inpatient Sample was queried from 2002 to 2011. Patients who underwent elective cervical spinal surgery were identified. Sentinel events including esophageal perforation, vascular injury, nerve injury, retention of foreign objects, and wrong-site surgery were identified. Patient demographics, comorbidities (Charlson Comorbidity Index), surgical procedures, length of stay, total hospital costs, and postoperative outcomes were assessed. The risk for in-hospital mortality associated with each complication was calculated using a 95% confidence interval (CI). Statistical analysis was performed with SPSS version 20, and a P ≤ 0.001 denoted significance. RESULTS A total of 251,318 cervical spine procedures were identified between 2002 and 2011, of which 123 patients (0.5 per 1000 cases) incurred sentinel events. Circumferential cervical fusion (anterior-posterior cervical fusion) demonstrated an increased risk of vascular injury (odds ratio [OR], 4.5; CI, 1.8-11.2), whereas cervical total disc replacement was associated with an increased risk of esophageal perforation (OR, 10.9; CI, 1.4-85.2) and nerve injury (OR, 36.4; CI, 1.5-892.3). Posterior cervical fusions were associated with an increased risk of wrong-site surgery (OR, 3.9; CI, 1.5-10.5). The sentinel event cohort incurred longer hospitalization, greater costs, mortality, and greater incidence of postoperative complications. CONCLUSION This database analysis demonstrates that sentinel events are associated with a significant increase in hospital resource utilization and worsened perioperative outcomes. The type of cervical spine procedure and the number of fusion levels significantly impact the risk of sentinel events. Further research is warranted to understand the etiology of sentinel events in cervical spine surgery and to implement protocols to mitigate the associated risk factors. LEVEL OF EVIDENCE 4.
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Lee SH, Kim JS, Jeong YC, Kwak DK, Chun JH, Lee HM. Patient safety in spine surgery: regarding the wrong-site surgery. Asian Spine J 2013; 7:63-71. [PMID: 23508946 PMCID: PMC3596588 DOI: 10.4184/asj.2013.7.1.63] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 10/04/2012] [Accepted: 10/04/2012] [Indexed: 11/08/2022] Open
Abstract
Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as regarding patient safety. Despite the many wrong-site surgery prevention campaigns in spine care such as the operate through your initial program by the Canadian Orthopaedic Association, the sign your site program by the American Academy of Orthopedic Surgeon, the sign, mark and X-ray program by the North American Spine Society, and the Universal Protocol program by the Joint Commission, the incidence of wrong-site surgery has not decreased. To prevent wrong-site surgery in spine surgeries, the spine surgeons must put patient safety first, complying with the hospital policies regarding patient safety. In the operating rooms, the surgeons need to do their best to level the hierarchy, enabling all to speak up if any patient safety concerns are noted. Changing the operating room culture is the essential part of the patient safety concerning spine surgery.
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Affiliation(s)
- Seung-Hwan Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Sup Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo-Chul Jeong
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dae-Kyung Kwak
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ja-Hae Chun
- Department of Quality Improvement and Patient Safety, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hwan-Mo Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
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Vachhani JA, Klopfenstein JD. Incidence of Neurosurgical Wrong-Site Surgery Before and After Implementation of the Universal Protocol. Neurosurgery 2012; 72:590-5; discussion 595. [DOI: 10.1227/neu.0b013e318283c9ea] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Although exceedingly rare, wrong-site surgery (WSS) remains a persistent problem in the United States. The incidence is thought to be 2 to 3 per 10 000 craniotomies and about 6 to 14 per 10 000 spine surgeries. In July 2004, the Joint Commission mandated the Universal Protocol (UP) for all accredited hospitals.
OBJECTIVE:
To assess the effect of UP implementation on the incidence of neurosurgical WSS at the University of Illinois College of Medicine at Peoria/Illinois Neurological Institute.
METHODS:
The Morbidity and Mortality Database in the Department of Neurosurgery was reviewed to identify all recorded cases of WSS since 1999. This was compared with the total operative load (excluding endovascular procedures) of all attending neurosurgeons to determine the incidence of overall WSS. A comparison was then made between the incidences before and after UP implementation.
RESULTS:
Fifteen WSS events were found with an overall incidence of 0.07% and Poisson 95% confidence interval of 8.4 to 25. All but one of these were wrong-level spine surgeries (14/15). There was only 1 recorded case of wrong-side surgery and this occurred after implementation of the UP. A statistically greater number of WSS events occurred before (n = 12) in comparison with after (n = 3) UP implementation (P < .001).
CONCLUSION:
A statistically significant reduction in overall WSS was seen after implementation of the UP. This reduction can be attributed to less frequent wrong-level spine surgery. There was no case of wrong procedure or patient surgery and the 1 case of wrong-side surgery occurred after UP implementation.
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Affiliation(s)
- Jay A. Vachhani
- Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine in Peoria, Peoria, Illinois
| | - Jeffrey D. Klopfenstein
- Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine in Peoria, Peoria, Illinois
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Wong JM, Bader AM, Laws ER, Popp AJ, Gawande AA. Patterns in neurosurgical adverse events and proposed strategies for reduction. Neurosurg Focus 2012; 33:E1. [DOI: 10.3171/2012.9.focus12184] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to reducing risk and to measuring and improving outcomes. The authors performed a review of patterns and frequencies of adverse events in neurosurgery as background for future efforts directed at the improvement of quality and safety in neurosurgery.
They found 6 categories of contributory factors in neurosurgical adverse events, categorizing the events as influenced by issues in surgical technique, perioperative medical management, use of and adherence to protocols, preoperative optimization, technology, and communication. There was a wide distribution of reported occurrence rates for many of the adverse events, in part due to the absence of definitive literature in this area and to the lack of standardized reporting systems.
On the basis of their analysis, the authors identified 5 priority recommendations for improving outcomes for neurosurgical patients at a population level: 1) development and implementation of a national registry for outcome data and monitoring; 2) full integration of the WHO Surgical Safety Checklist into the operating room workflow, which improves fundamental aspects of surgical care such as adherence to antibiotic protocols and communication within surgical teams; and 3–5) activity by neurosurgical societies to drive increased standardization for the safety of specialized equipment used by neurosurgeons (3), more widespread regionalization and/or subspecialization (4), and establishment of data-driven guidelines and protocols (5). The fraction of adverse events that might be avoided if proposed strategies to improve practice and decrease variability are fully adopted remains to be determined. The authors hope that this consolidation of what is currently known and practiced in neurosurgery, the application of relevant advances in other fields, and attention to proposed strategies will serve as a basis for informed and concerted efforts to improve outcomes and patient safety in neurosurgery.
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Affiliation(s)
- Judith M. Wong
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 3Departments of Neurosurgery,
| | - Angela M. Bader
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 4Anesthesiology, Perioperative and Pain Medicine, and
| | | | | | - Atul A. Gawande
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 5Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Longo UG, Loppini M, Romeo G, Maffulli N, Denaro V. Errors of level in spinal surgery. ACTA ACUST UNITED AC 2012; 94:1546-50. [DOI: 10.1302/0301-620x.94b11.29553] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.
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Affiliation(s)
- U. G. Longo
- Campus Bio-medico University, Department
of Orthopaedic and Trauma Surgery, Via Alvaro
del Portillo 200, 00128 Trigoria, Rome, Italy
| | - M. Loppini
- Campus Bio-medico University, Department
of Orthopaedic and Trauma Surgery, Via Alvaro
del Portillo 200, 00128 Trigoria, Rome, Italy
| | - G. Romeo
- Campus Bio-medico University, Department
of Orthopaedic and Trauma Surgery, Via Alvaro
del Portillo 200, 00128 Trigoria, Rome, Italy
| | - N. Maffulli
- Centre for Sport and Exercise Medicine, Barts
and the London School of Medicine and Dentistry, Mile
End Hospital, Queen Mary University of London, 275
Bancroft Road, London E1 4DG, UK
| | - V. Denaro
- Campus Bio-medico University, Department
of Orthopaedic and Trauma Surgery, Via Alvaro
del Portillo 200, 00128 Trigoria, Rome, Italy
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Masquelet's procedure and bone morphogenetic protein in congenital pseudarthrosis of the tibia in children: a case series and meta-analysis. J Child Orthop 2012; 6:297-306. [PMID: 23904896 PMCID: PMC3425695 DOI: 10.1007/s11832-012-0421-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 07/02/2012] [Indexed: 02/03/2023] Open
Abstract
PURPOSE A type 2 recombinant human bone morphogenetic protein (rhBMP2) and Masquelet's procedure were used in three children presenting with congenital pseudarthrosis of the tibia (CPT). Recent studies on CPT suggested the presence in situ of pathologic tissues promoting pseudarthrosis. The authors hypothesized that large segmental resection of pseudarthrosis could improve prognosis of the CPT. Masquelet's procedure and rhBMP2 have been advocated for the treatment of long bone defect. METHOD The authors report three cases of CPT in children treated with Masquelet's procedure and application of rhBMP2. They analyzed all published cases of CPT similarly treated. RESULTS In the present study, Masquelet's procedure did not improve the results in the treatment of CPT, but segmental bone reconstruction was possible. Bone healing was obtained in three out of the five applications of rhBMP2. In one case, the patient's parents asked for leg amputation. Analysis of the 33 published cases with the application of BMP in CPT points to a 62 % healing rate in this pathology. CONCLUSION The authors confirmed that segmental bone reconstruction is possible in CPT using Masquelet's procedure. In the literature, the success rate of the application of rhBMP in CPT appears to be lower than the healing rate usually reported without BMP. Nevertheless, the strict selection of patients, limited number of cases, and their heterogeneity make interpreting the results difficult. However, the theoretical risk which the children are exposed to during the use of BMP makes rigorous selection of the indications necessary. Finally, the interest of rhBMP2 application in Masquelet's procedure remained to be proven.
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Irace C, Usai S. The 'nightmare' of wrong level in spine surgery: a critical appraisal. Patient Saf Surg 2012; 6:14. [PMID: 22713236 PMCID: PMC3468363 DOI: 10.1186/1754-9493-6-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 05/15/2012] [Indexed: 11/10/2022] Open
Abstract
The recent article published in the Journal by Lindley and colleagues (Patient Saf. Surg. 2011, 5:33) reported the successful surgical treatment of a persistent thoracic pain following a T7-8 microdiscectomy, truly performed at the ‘level immediately above’. The wrong level in spine surgery is a multi-factorial matter and several strategies have been designed and adopted to try decreasing its occurrence. We think that three of these factors are crucial: global strategy, attention, precision in level identification; and the actors we identified are the surgeon, the assistant nurse and the (neuro)radiologist respectively. Basing upon our experience, the role of the radiologist pre- and intraoperatively and the importance of the assistant nurse are briefly described.
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Affiliation(s)
- Claudio Irace
- Dept of Neurosurgery, Hospital IGEA, Via Marcona 69, Milan, 20129, Italy.
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Thampi SP, Rekhala V, Vontobel T, Nukula V. Patient safety in interventional pain procedures. Phys Med Rehabil Clin N Am 2012; 23:423-32. [PMID: 22537703 DOI: 10.1016/j.pmr.2012.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The objective of this article was to present a systematic review of the safety issues encountered in interventional pain management. Patient safety is an important consideration in the practice of interventional pain management. Although there is a paucity of scientific articles addressing this topic, the authors have reviewed the literature and present a review of the topic, as well as strategies to minimize the risk to patients undergoing interventional spine procedures.
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Affiliation(s)
- Samuel P Thampi
- Department of Physical Medicine and Rehabilitation, Kingsbrook Jewish Medical Center, 585 Schenectady Avenue, Suite 224, Brooklyn, NY 11203, USA.
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Irace C, Corona C. How to avoid wrong-level and wrong-side errors in lumbar microdiscectomy. J Neurosurg Spine 2010; 12:660-5. [PMID: 20515352 DOI: 10.3171/2009.12.spine09627] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT When performing a single-level lumbar decompressive procedure, the first of all errors to avoid is operating at the wrong level or on the wrong side. In this report the authors describe their method of trying to minimize this potential risk. METHODS A 3-step procedure-the IRACE (intraoperative radiograph and confirming exclamation) method-was designed and adopted for single-level lumbar decompressive surgeries. Before skin incision, a wire is placed in the spinous process and lateral fluoroscopy is performed. Subsequently and also before skin incision, the assistant nurse provides oral confirmation of the level and side. Additional fluoroscopic control is provided before starting the laminotomy. The clinical records of 818 consecutive patients who had undergone lumbar microdiscectomy as an initial operation between 2001 and 2005 were retrospectively reviewed. Surgical charts as well as clinical and neuroimaging follow-up data were analyzed. RESULTS No patient clinically and/or neuroradiologically demonstrated a level or side error. In 1 (0.12%) of 818 surgical procedures a wrong level was initially explored. The absence of frank disc herniation and the discrepancy with preoperative neuroimages led to fluoroscopic control in this case, and the correct level was then approached. No clinically apparent method-related complications were registered. CONCLUSIONS The problem of an incorrect level or side in lumbar surgery remains unresolved. The authors propose a useful and easily applied procedure to reduce such a risk. Larger studies comparing different methods of avoiding such errors will probably lead to the definition and wide adoption of a surgical behavior aiming to reach a near-zero error rate.
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Affiliation(s)
- Claudio Irace
- Department of Neurosurgery, Hospital Igea, Milan, Italy.
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Abstract
STUDY DESIGN Systematic review. OBJECTIVE To report the incidence and causes of wrong site surgery and determine what preoperative measures are effective in preventing wrong site surgery. SUMMARY OF BACKGROUND DATA From 1995 to 2005, the Joint Commission (JC) sentinel event statistics database ranked wrong site surgery as the second most frequently reported event with 455 of 3548 sentinel events (12.8%). Although the event seems to be rare, the incidence of these complications has been difficult to measure and quantify. The implications for wrong site surgery go beyond the effects to the patient. Such an event has profound medical, legal, social, and emotional implications. METHODS A systematic review of the English language literature was undertaken for articles published between 1990 and December 2008. Electronic databases and reference lists of key articles were searched to identify the articles defining wrong site surgery and reporting wrong site events. Two independent reviewers assessed the level of evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation criteria and disagreements were resolved by consensus. RESULTS The estimated rate of wrong site surgery varies widely ranging from 0.09 to 4.5 per 10,000 surgeries performed. There is no literature to substantiate the effectiveness of the current JC Universal Protocol in decreasing the rate of wrong site, wrong level surgery. CONCLUSION Wrong site surgery may be preventable. We suggest that the North American Spine Society and JC checklists are insufficient on their own to minimize this complication. Therefore, in addition to these protocols, we recommend intraoperative imaging after exposure and marking of a fixed anatomic structure. This imaging should be compared with routine preoperative studies to determine the correct site for spine surgery.
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A new journal devoted to patient safety in surgery: the time is now! Patient Saf Surg 2007; 1:1. [PMID: 18271986 PMCID: PMC2222679 DOI: 10.1186/1754-9493-1-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2007] [Accepted: 11/07/2007] [Indexed: 12/03/2022] Open
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Fehlings MG. Reducing medical errors: an essential aspect of neurosurgical practice. J Neurosurg Spine 2007; 7:465-6; discussion 466. [DOI: 10.3171/spi-07/11/465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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