TY - JOUR
T1 - An Update on Wrong-Site Spine Surgery
AU - DeVine, John G.
AU - Chutkan, Norman
AU - Gloystein, David
AU - Jackson, Keith
N1 - Funding Information:
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. wrong-site surgery wrong-site spine surgery wrong level wrong patient wrong side typesetter ts3 Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This supplement was supported by funding from AO Spine North America. ORCID iD John G. DeVine, MD, FAOA https://orcid.org/0000-0002-8958-2996
Publisher Copyright:
© The Author(s) 2020.
PY - 2020/1/1
Y1 - 2020/1/1
N2 - 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.
AB - 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.
KW - wrong level
KW - wrong patient
KW - wrong side
KW - wrong-site spine surgery
KW - wrong-site surgery
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U2 - 10.1177/2192568219846911
DO - 10.1177/2192568219846911
M3 - Article
AN - SCOPUS:85077713289
SN - 2192-5682
VL - 10
SP - 41S-44S
JO - Global Spine Journal
JF - Global Spine Journal
IS - 1_suppl
ER -