Wrong-Level Spine Surgery.

Abstract

In 1999 the Institute of Medicine published its landmark report, To Err is Human: Building a Safer Health System, in which it was estimated that between 44,000 and 98,000 preventable hospital deaths occur annually in the United States due to human error1. Subsequently, state-based and federal-based initiatives including the National Summit on Medical Errors and Patient Safety, the National Quality Forum, the Agency for Healthcare Research and Quality, and The Joint Commission were tasked with identifying ways to reduce medical errors and improve patient safety. Medical societies such as the American Academy of Orthopaedic Surgeons (AAOS) and the North American Spine Society have similarly made recommendations to improve patient care through the publication of procedural guidelines2,3. Wrong-patient, wrong-side, or wrong-site surgery falls under The Joint Commission’s designation of a sentinel event, which is defined as “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” to the patient4. One study found that 84% of wrong-site surgery malpractice claims led to patient indemnity versus 30% for other orthopaedic complications5. The Joint Commission, which collects data on sentinel events, has identified wrong-site, wrong-side, or wrong-patient surgery as one of the most frequently, annually reported sentinel events. In fact, it was the most commonly reported sentinel event6 (928 [13.3%] …