Rare anatomical differences in a particular individual may throw a wrench into what was expected to be a routine spine surgery. In the September 2012 issue of First Do No Harm, an article discusses five cases at a New England hospital of such an occurrence in which patients were operated on at the wrong level of the spine. These unfortunate errors happened even though correct protocols were followed.
Gail Sebet, MSM, RN, Senior Director, Surgical Services and Maureen Broms, MS, RN, Vice President, Health Care Quality, Informatics and Research co-authored the article. The two pinpointed several ways in which wrong-site surgery occurred despite the fact that the surgical team followed specific protocols intended to prevent such medical errors.
These cases often arise due to unexpected anatomical distinctions in a particular individual. Even when spine surgeons and their teams follow protocols, including taking intra-operative films, it’s no guarantee a patient will not suffer unintended harm during the operation. In fact, following an investigation of these five cases, the authors concluded in these particular instances that wrong-site spinal surgery followed good practices.
Changes in the hospital’s procedures to ensure accurate intra-operative site marking included ceasing the use of movable markers, making it much more difficult for the surgeon to make a mistake in the location and level of the patient’s spine.
New England Baptist Hospital also instituted other changes in protocol to prevent wrong-site surgery, including an increase in reviews of pre-operative images for cases in which there were any questions over abnormalities.