From Operating Room to Courtroom: Analyzing Malpractice Trajectories in Cranial Neurosurgery

BACKGROUND AND OBJECTIVES

Nearly all neurosurgeons in the United States will be named defendants in a malpractice claim before retirement. We perform an assessment of national malpractice trends in cranial neurosurgery to inform neurosurgeons on current outcomes, trends over time, benchmarks for malpractice coverage needs, and ways to mitigate lawsuits.

METHODS

The Westlaw Edge and LexisNexis databases were searched to identify medical malpractice cases relating to open cranial surgery between 1987 and 2023. Extracted data included date of verdict, jurisdiction, outcome, details of sustained injuries, and any associated award/settlement figures.

RESULTS

Of 1550 cases analyzed, 252 were identified as malpractice claims arising from open cranial surgery. The median settlement amount was $950 000 and the average plaintiff ruling was $2 750 000. The highest plaintiff ruling resulted in an award of $28.1 million. Linear regression revealed no significant relationship between year and defendant win (P-value = .43). After adjusting for inflation, award value increased with time (P-value = .01). The most common cranial subspecialties were tumor (67 cases, 26.6%), vascular (54 cases, 21.4%), infection (23 cases, 9.1%), and trauma (23 cases, 9.1%). Perioperative complications was the most common litigation category (96 cases, 38.1%), followed by delayed treatment (40 cases, 15.9%), failure to diagnose (38 cases, 15.1%), and incorrect choice of procedure (29 cases, 11.5%). The states with most claims were New York (40 cases, 15.9%), California (24 cases, 9.5%), Florida (21 cases, 8.3%), and Pennsylvania (20 cases, 7.9%).

CONCLUSION

Although a stable number of cases were won by neurosurgeons, an increase in award sizes was observed in the 37-year period assessed. Perioperative complications and delayed treatment/diagnosis were key drivers of malpractice claims.

Neurosurgical Wrong Surgical Site in Lower-Middle- or Low-Income Countries (LMICs): A Survey Study

BACKGROUND

One of the most preventable errors of a surgeon's career is operating on the incorrect surgical site (ICSS). No study in any specialty has ever investigated the incidence of ICSS events in lower-income countries. This study focuses on identifying the occurrence of these events along with an analysis of potential causes leading to these unfortunate events.

METHODS

The authors distributed a survey to neurosurgical colleagues from around the world. These surgeons were first asked to identify details about their practice and incidence and personal experience with ICSS in their own careers. At the end of the survey, they responded to questions about their knowledge of safety checklists.

RESULTS

In this study there was a 63.4% response rate. When combined with those who participated through various social media platforms, there were 178 responses. The incidence rate for every 10,000 cases performed was found to be 22.8 in the cranial group, 88.6 in the cervical group, and 158.8 in the lumbar procedural group. This study identified that 40% of participants had never learned or experienced the ABCD time-out strategy and that 60% of surgeons did not use intraoperative navigation or imaging in their practices. The error has never been disclosed to the patient in 48% of the ICSS cases.

CONCLUSIONS

Due to a lack of application of safety checklist protocol, there is an increased occurrence of ICSS events in lower-income countries. The results of this study demonstrate the necessity of investing time and resources dedicated to avoiding preventable errors.

Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities

Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.

Medical malpractice in spine surgery: a review

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.

An Update on Wrong-Site Spine Surgery

STUDY DESIGN

Broad narrative review of current literature and adverse event databases.

OBJECTIVE

The aim of this review is to report the current state of wrong-site spine surgery (WSSS), whether the Universal Protocol has affected the rate, and the current trends regarding WSSS.

METHODS

An updated review of the current literature on WSSS, the Joint Commission sentinel event statistics database, and other state adverse event statistics database were performed.

RESULTS

WSSS is an adverse event that remains a potentially devastating problem, and although the incidence is difficult to determine, the rate is low. However, given the potential consequences for the patient as well as the surgeon, WSSS remains an event that continues to be reported alarmingly as often as before the implementation of the Universal Protocol.

CONCLUSIONS

A systems-based approach like the Universal Protocol should be effective in preventing wrong-patient, wrong-procedure, and wrong-sided surgeries if the established protocol is implemented and followed consistently within a given institution. However, wrong-level surgery can still occur after successful completion of the Universal Protocol. The surgeon is the sole provider who can establish the correct vertebral level during the operation, and therefore, it is imperative that the surgeon design and implement a patient-specific protocol to ensure that the appropriate level is identified during the operation.

Using Hourly Time-Outs and a Standardized Tool to Promote Team Communication, Medical Record Documentation, and Patient Satisfaction During Second-Stage Labor

BACKGROUND

During labor, effective communication and collaboration among the healthcare team is critical for patient safety; however, there is currently no standard for communication and documentation of the plan of care as agreed upon by healthcare team members and the woman in labor.

OBJECTIVES

The goal of this project was to increase consistency in communication and collaboration between clinicians and laboring women during second-stage labor.

METHODS

An hourly "time-out" meeting of all healthcare team members was initiated for all women during second-stage labor. A documentation tool was implemented to ensure regular and clear communication between the clinical team and laboring women. Data were collected via medical review of cases of second-stage labor lasting more than 2 hours (n = 21 in the pre-implementation group; n = 39 for 3 months postimplementation; and n = 468 patients for 2 years post-implementation). Surveys were conducted of the clinical team (n = 40) and patients (n = 28).

RESULTS

Following implementation, documented agreement of the plan of care increased from 14.3% before the project to 82.1% 3 months after implementation and remained at 81.6% 2 years after implementation. All nurses who participated in the survey reported a clear understanding of how and when to complete necessary medical record documentation during second-stage labor. The providers viewed the project favorably. Most women (92.9%) reported satisfaction with their experience. This project enhanced collaborative communication between members of the clinical team and laboring women and improved patient satisfaction. The improvements were sustainable over a 2-year period.

Incidence of Wrong-Site Surgery List Errors for a 2-Year Period in a Single National Health Service Board

Introduction

Wrong-site/side surgical “never events” continue to cause considerable harm to patients, healthcare professionals, and organizations within the United Kingdom. Incidence has remained static despite the mandatory introduction of surgical checklists. Operating theater list errors have been identified as a regular contributor to these never events. The aims of the study were to identify and to learn from the incidence of wrong-site/side list errors in a single National Health Service board.

Methods

The study was conducted in a single National Health Service board serving a population of approximately 300,000. All theater teams systematically recorded errors identified at the morning theater brief or checklist pause as part of a board-wide quality improvement project. Data were reviewed for a 2-year period from May 2013 to April 2015, and all episodes of wrong-site/side list errors were identified for analysis.

Results

No episodes of wrong-site/side surgery were recorded for the study period. A total of 86 wrong-site/side list errors were identified in 29,480 cases (0.29%). There was considerable variation in incidence between surgical specialties with ophthalmology recording the largest proportion of errors per number of surgical cases performed (1 in 87 cases) and gynecology recording the smallest proportion (1 in 2671 cases). The commonest errors to occur were “wrong-side” list errors (62/86, 72.1%).

Discussion

This is the first study to identify incidence of wrong-site/site list errors in the United Kingdom. Reducing list errors should form part of a wider risk reduction strategy to reduce wrong-site/side never events. Human factors barrier management analysis may help identify the most effective checks and controls to reduce list errors incidence, whereas resilience engineering approaches should help develop understanding of how to best capture and neutralize errors.

Total Navigation in Spine Surgery; A Concise Guide to Eliminate Fluoroscopy Using a Portable Intraoperative Computed Tomography 3-Dimensional Navigation System

BACKGROUND

Portable intraoperative computed tomography (iCT) with integrated 3-dimensional navigation (NAV) offers new opportunities for more precise navigation in spinal surgery, eliminates radiation exposure for the surgical team, and accelerates surgical workflows. We present the concept of "total navigation" using iCT NAV in spinal surgery. Therefore, we propose a step-by-step guideline demonstrating how total navigation can eliminate fluoroscopy with time-efficient workflows integrating iCT NAV into daily practice.

METHODS

A prospective study was conducted on collected data from patients undergoing iCT NAV-guided spine surgery. Number of scans, radiation exposure, and workflow of iCT NAV (e.g., instrumentation, cage placement, localization) were documented. Finally, the accuracy of pedicle screws and time for instrumentation were determined.

RESULTS

iCT NAV was successfully performed in 117 cases for various indications and in all regions of the spine. More than half (61%) of cases were performed in a minimally invasive manner. Navigation was used for skin incision, localization of index level, and verification of implant position. iCT NAV was used to evaluate neural decompression achieved in spinal fusion surgeries. Total navigation eliminates fluoroscopy in 75%, thus reducing staff radiation exposure entirely. The average times for iCT NAV setup and pedicle screw insertion were 12.1 and 3.1 minutes, respectively, achieving a pedicle screw accuracy of 99%.

CONCLUSIONS

Total navigation makes spine surgery safer and more accurate, and it enhances efficient and reproducible workflows. Fluoroscopy and radiation exposure for the surgical staff can be eliminated in the majority of cases.

Prevention training of wrong-site spine surgery

OBJECTIVE

Wrong-site surgery (WSS) is considered a sentinel event by the Joint Commission. The education of spine surgery fellows on WSS is unknown. Our objective was to evaluate North American spine surgery fellows' education, awareness, and experience with WSS.

DESIGN

Observational survey study.

SETTING

Spine surgery fellows in North America.

PARTICIPANTS

From April 2013 to July 2013 and in July 2014 anonymous questionnaires were sent to 156 spine surgery fellows participating in 75 programs. Demographic information (fellowship location and Accreditation Council for Graduate Medical Education accreditation of the fellowship) were collected. We also collected data on the following: if didactics on WSS are offered during fellowship, spine surgery fellows' experience with WSS, WSS prevention methods used during fellowship, and whether spine surgery fellows are interested in didactics or webinars on the prevention of WSS.

RESULTS

Of 152 spine surgery fellows, 46 (30.3%) completed the questionnaires. Among them, 39 (84.6%) were orthopedic surgeons and 7 (15.4%) were neurosurgeons. Most were in non-Accreditation Council for Graduate Medical Education-accredited programs (70%) and were in training in the Midwest (37%), the South (30.4%), the Northeast (15.2%), and the West (15.2%). Furthermore, 30.4% had experienced WSS. Only 15 fellows (33%) had formal didactics on WSS during their fellowship. Most spine surgery fellows (61%, p = 0.03) were interested in a formal didactics on the prevention of WSS during their fellowship curriculum. Most (58.7%) were also interested in a Webinar on the prevention of WSS. We found of the 14 fellows that experienced WSS, 11 (79%) were significantly interested in formal didactics on WSS compared with those who had not experienced WSS (14/32, 44%; p < 0.02).

CONCLUSIONS

This is the first study evaluating spine surgery fellowship education on WSS. Among the spine surgery fellows, 30% had already experienced WSS and only 33% had formal fellowship didactics on WSS. Owing to the significant patient care and medicolegal ramifications from WSS, spine surgery fellowships should consider adding WSS prevention didactics to their curriculum.

Interventions for reducing wrong-site surgery and invasive clinical procedures

BACKGROUND

Specific clinical interventions are needed to reduce wrong-site surgery, which is a rare but potentially disastrous clinical error. Risk factors contributing to wrong-site surgery are variable and complex. The introduction of organisational and professional clinical strategies have a role in minimising wrong-site surgery.

OBJECTIVES

To evaluate the effectiveness of organisational and professional interventions for reducing wrong-site surgery (including wrong-side, wrong-procedure and wrong-patient surgery), including non-surgical invasive clinical procedures such as regional blocks, dermatological, obstetric and dental procedures and emergency surgical procedures not undertaken within the operating theatre.

SEARCH METHODS

For this update, we searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014), MEDLINE (June 2011 to January 2014), EMBASE (June 2011 to January 2014), CINAHL (June 2011 to January 2014), Dissertations and Theses (June 2011 to January 2014), African Index Medicus, Latin American and Caribbean Health Sciences database, Virtual Health Library, Pan American Health Organization Database and the World Health Organization Library Information System. Database searches were conducted in January 2014.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs), non-randomised controlled trials, controlled before-after studies (CBAs) with at least two intervention and control sites, and interrupted-time-series (ITS) studies where the intervention time was clearly defined and there were at least three data points before and three after the intervention. We included two ITS studies that evaluated the effectiveness of organisational and professional interventions for reducing wrong-site surgery, including wrong-side and wrong-procedure surgery. Participants included all healthcare professionals providing care to surgical patients; studies where patients were involved to avoid the incorrect procedures or studies with interventions addressed to healthcare managers, administrators, stakeholders or health insurers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assesses the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information.

MAIN RESULTS

In the initial review, we included one ITS study that evaluated a targeted educational intervention aimed at reducing the incidence of wrong-site tooth extractions. The intervention included examination of previous cases of wrong-site tooth extractions, educational intervention including a presentation of cases of erroneous extractions, explanation of relevant clinical guidelines and feedback by an instructor. Data were reported from all patients on the surveillance system of a University Medical centre in Taiwan with a total of 24,406 tooth extractions before the intervention and 28,084 tooth extractions after the intervention. We re-analysed the data using the Prais-Winsten time series and the change in level for annual number of mishaps was statistically significant at -4.52 (95% confidence interval (CI) -6.83 to -2.217) (standard error (SE) 0.5380). The change in slope was statistically significant at -1.16 (95% CI -2.22 to -0.10) (SE 0.2472; P < 0.05).This update includes an additional study reporting on the incidence of neurological WSS at a university hospital both before and after the Universal Protocol's implementation. A total of 22,743 patients undergoing neurosurgical procedures at the University of Illionois College of Medicine at Peoria, Illinois, United States of America were reported. Of these, 7286 patients were reported before the intervention and 15,456 patients were reported after the intervention. The authors found a significant difference (P < 0.001) in the incidence of WSS between the before period, 1999 to 2004, and the after period, 2005 to 2011.  Similarly, data were re-analysed using Prais-Winsten regression to correct for autocorrelation. As the incidences were reported by year only and the intervention occurred in July 2004, the intervention year 2004 was excluded from the analysis. The change in level at the point the intervention was introduced was not statistically significant at -0.078 percentage points (pp) (95% CI -0.176 pp to 0.02 pp; SE 0.042; P = 0.103). The change in slope was statistically significant at 0.031 (95% CI 0.004 to 0.058; SE 0.012; P < 0.05).

AUTHORS' CONCLUSIONS

The findings of this update added one additional ITS study to the previous review which contained one ITS study. The original review suggested that the use of a specific educational intervention in the context of a dental outpatient setting, which targets junior dental staff using a training session that included cases of wrong-site surgery, presentation of clinical guidelines and feedback by an instructor, was associated with a reduction in the incidence of wrong-site tooth extractions. The additional study in this update evaluated the annual incidence rates of wrong-site surgery in a neurosurgical population before and after the implementation of the Universal Protocol. The data suggested a strong downward trend in the incidence of wrong-site surgery prior to the intervention with the incidence rate approaching zero. The effect of the intervention in these studies however remains unclear, as data reflect only two small low-quality studies in very specific population groups.

Adverse events in neurosurgery and their relationship to quality improvement

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.

Radiograms Obtained during Anterior Cervical Decompression and Fusion Can Mislead Surgeons into Performing Surgery at the Wrong Level

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.

"It is the left eye, right?"

Objective

Because wrong-site confusion is among the most common mistakes in the operations of paired organs, we have examined the frequency of wrong-sided confusions that could theoretically occur in cataract surgeries in the absence of preoperative verification.

Methods

Ten cataract surgeons participated in the study. The surgeons were asked to complete a questionnaire that included their demographic data, occupational habits, and their approach to and the handling of patients preoperatively. On the day of operation, the surgeons were asked to recognize the side of the operation from the patient’s name only. At the second stage of the study, surgeons were asked to recognize the side of the operation while standing a 2-meter distance from the patient’s face. The surgeons’ answers were compared to the actual operation side. Patients then underwent a full time-out procedure, which included side marking before the operation.

Results

Of the total 67 patients, the surgeons correctly identified the operated side of the eye in 49 (73%) by name and in 56 (83%) by looking at patients’ faces. Wrong-side identification correlated with the time lapsed from the last preoperative examination (P=0.034). The number of cataract surgeries performed by the same surgeon (on the same day) also correlated to the number of wrong identifications (P=0.000). Surgeon seniority or age did not correlate to the number of wrong identifications.

Conclusion

This study illustrates the high error rate that can result in the absence of side marking prior to cataract surgery, as well as in operations on other paired organs.