Watts Bradley V, Rachlin Jacob R, Gunnar William, Mills Peter D, Neily Julia, Soncrant Christina, Paull Douglas E
VA National Center for Patient Safety, Ann Arbor, MI.
White River Junction VAMC, VT.
Clin Spine Surg. 2019 Dec;32(10):454-457. doi: 10.1097/BSD.0000000000000771.
Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA).
To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue.
Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients.
We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated.
There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues.
Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.
对退伍军人健康管理局（VHA）中脊柱手术错误节段的事件特征进行基本描述性分析。
确定VHA中报告的脊柱手术节段错误的发生频率、事件的因果因素，并提出该问题的解决方案。
手术部位错误是向联合委员会报告的最常见事件之一。据报道，50%的脊柱外科医生在其职业生涯中至少经历过1次手术部位错误事件，这些事件会对患者造成严重伤害。
我们检查了2000年至2017年期间向VHA国家患者安全中心（NCPS）报告的脊柱手术节段错误不良事件。通过将手术部位错误病例数除以研究期间脊柱手术总数来确定手术部位错误率。同样，计算了骨科医生和神经外科医生的手术部位错误率。
2000年至2017年期间共报告了32例手术部位错误的脊柱手术病例。14例涉及颈椎区域，13例涉及腰椎区域，5例涉及胸椎区域。大多数根本原因（69%或69个根本原因中的48个）可分为两大类：X光片问题或术中标记问题。这些并非相互排斥，一些根本原因分析涉及不止一个此类问题。
脊柱手术节段错误是该领域面临的一个重大安全问题，尽管手术团队遵循了指南，但此类事件仍在继续发生。由于X光片质量差和可解释性差是这些事件最常见的根本原因，旨在优化图像质量和准确解读的干预措施将是合乎逻辑的首要行动。
