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从脊柱手术错误到错误节段手术的预防:综述

From error to prevention of wrong-level spine surgery: a review.

作者信息

Javadnia Parisa, Gohari Hasti, Salimi Nila, Alimohammadi Ehsan

机构信息

Department of neurosurgery, Iran University of Medical Sciences, Tehran, Iran.

Department of neurosurgery, Kermanshah University of Medical Sciences, Kermanshah, Iran.

出版信息

Patient Saf Surg. 2025 May 15;19(1):16. doi: 10.1186/s13037-025-00440-4.

Abstract

Wrong-level spine surgery remains a significant concern in spine surgery, leading to devastating consequences for patients and healthcare systems alike. This comprehensive review aims to analyze the existing literature on wrong-level spine surgery in spine procedures, identifying key factors that contribute to these errors and exploring advanced strategies and technologies designed to prevent them. A systematic literature search was conducted across multiple databases, including PubMed, Scopus, EMBASE, and CINAHL. The selection criteria focused on preclinical and clinical studies that specifically addressed wrong site and wrong level surgeries in the context of spine surgery. The findings reveal a range of contributing factors to wrong-level spine surgeries, including communication failures, inadequate preoperative planning, and insufficient surgical protocols. The review emphasizes the critical role of innovative technologies-such as artificial intelligence, advanced imaging techniques, and surgical navigation systems-alongside established safety protocols like digital checklists and simulation training in enhancing surgical accuracy and preventing errors. In conclusion, integrating advanced technologies and systematic safety protocols is instrumental in reducing the incidence of wrong-level spine surgeries. This review underscores the importance of continuous education and the adoption of innovative solutions to foster a culture of safety and improve surgical outcomes. By addressing the multifaceted challenges associated with these errors, the field can work towards minimizing their occurrence and enhancing patient care.

摘要

脊柱手术中手术节段错误仍然是脊柱外科手术中的一个重大问题,给患者和医疗系统都带来了灾难性后果。这篇综述旨在分析脊柱手术中有关手术节段错误的现有文献,确定导致这些错误的关键因素,并探索旨在预防这些错误的先进策略和技术。我们在多个数据库中进行了系统的文献检索,包括PubMed、Scopus、EMBASE和CINAHL。选择标准侧重于在脊柱手术背景下专门针对手术部位错误和手术节段错误的临床前和临床研究。研究结果揭示了导致手术节段错误的一系列因素,包括沟通失误、术前规划不足和手术方案不完善。该综述强调了创新技术(如人工智能、先进成像技术和手术导航系统)以及数字检查表和模拟训练等既定安全协议在提高手术准确性和预防错误方面的关键作用。总之,整合先进技术和系统安全协议有助于降低手术节段错误的发生率。这篇综述强调了持续教育以及采用创新解决方案以培养安全文化和改善手术效果的重要性。通过应对与这些错误相关的多方面挑战,该领域可以努力减少其发生并提高患者护理质量。

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