Wrong-level spine surgeries, due to miscounting the vertebrae, are a common kind of surgical error because the 33 vertebrae look similar, the Globe said. However, just 11 spine surgery errors were reported to the state between 2006 and 2008, and the hospital couldn’t explain why three such mistakes occurred in just two months.
A quality control physician at the hospital said both surgeons involved in the mistakes are experienced and followed standard safety procedures, such as taking a “time out” to verify the type and location of the surgery. But in one case, the surgeon and the spine surgery fellow assisting him had different understandings of how to count and mark the correct vertebrae.
The hospital has made improvements since the mistakes, such as introducing a checklist developed by New England Baptist Hospital to help surgeons mark the correct vertebrae in the OR. It has also hired an outside expert to review spine surgery procedures.
Beth Israel did not identify the surgeons. The hospital said none of the patients suffered harmful effects from the mistakes, but an attorney for one of the patients said she did experience problems.
Read the Boston Globe report on wrong site surgery in spinal procedures.
Read more coverage of wrong-site surgery.
– Study: Wrong-Site and Wrong-Patient Procedures Continue
– Joint Commission Updates Universal Protocol
