Abstract
BackgroundWe previously reported on a series of side errors in cranial neurosurgery that occurred around the UK before the year 2006. That survey was prompted by a cluster of six cranial and spinal side errors that occurred in the neurosurgery department in Newcastle upon Tyne during the year 2006. The report was part of our investigation into the problem and how to solve it.MethodsA human factors training programme was run in the department in response to a further side error. All 125 members of the neurosurgical theatre staff attended 1 of 5 training days. Fifteen days of professional observation and coaching were held within the theatre suite. Time between errors was recorded. The success or otherwise of human factors measures such as checking and briefing was observed.ResultsA side checking system was adopted and became universal. Pre-list briefing meetings were adopted and quickly became widely used but took several years to become universal. Post-list debriefing meetings were introduced but were not widely adopted and quickly fell out of use. Mean time between side errors was 2 months pre-intervention, 18 months after introducing a standardised checking system and 82 error free months had passed since the human factors training programme.ConclusionsSide errors in neurosurgery can be reduced by a combination of systematic checking and education. We suspect that education is useful in reducing error rates from low to very low but, as is generally true of human factor interventions, the evidence for this is soft.
Highlights
Operating on the wrong side is a special case of wrong site surgery that is poorly tolerated by the general public because of its understandable nature
In 1997 the American Academy of Orthopaedic Surgeons (AAOS) formed a task force on wrong site surgery that measured the incidence of such errors and began a “Sign Your Site” campaign to promote preoperative site marking
In this article we examine this error and action taken to further reduce the error rate
Summary
Operating on the wrong side is a special case of wrong site surgery that is poorly tolerated by the general public because of its understandable nature. In 1997 the American Academy of Orthopaedic Surgeons (AAOS) formed a task force on wrong site surgery that measured the incidence of such errors and began a “Sign Your Site” campaign to promote preoperative site marking. This was followed by similar campaigns by the Joint Commission on Accreditation of Healthcare Organizations, US Veteran’s Health Administration, Canadian Orthopaedic and the North American Spine Society Associations [1]. These highlighted pre-operative site marking as a mainstay of error prevention. Mean time between side errors was 2 months pre-intervention, 18 months after introducing a standardised checking system and 82 error free months had passed since the human factors training programme
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