Wrong site spinal surgery in the Veterans Health Administration — Study identifies 2 leading causes 

Written by Shayna Korol | January 28, 2019 | Print  |

Problems with the radiograph or intraoperative markers were the leading root causes of wrong site spinal surgery in the Veterans Health Administration, according to a study in Clinical Spine Surgery.

The researchers assessed incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety between 2000 and 2017.

There were 32 reported cases of wrong site spine surgery:

  • 14 cases involved the cervical region
  • 13 cases involved the lumbar region
  • 5 cases involved the thoracic region

The majority of the problems — 48 of 69 causes — were due to issues with the radiograph or problems with the intraoperative marker. These problems were not mutually exclusive. 

Interventions should aim to optimize image quality and accurate interpretation, the study authors concluded. 

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