P97. Reducing wrong-site spine surgeries: an update of a single tertiary institution's iterative policy

• Published in: The spine journal 2024-09, Vol.24 (9), p.S110-S110
• Main Authors: Shah, Aakash, Meade, Seth M, Shost, Michael, Krishnaney, Ajit A.
• Format: Article
• Language: English
• ISSN: 1529-9430
• DOI: 10.1016/j.spinee.2024.06.118

Wrong-site spine surgery (WSSS) is a rare adverse event associated with spinal surgery and is considered a “never event” by the Agency for Health care Research and Quality. A WSSS is any spinal procedure conducted on an unintended anatomic location along the spinal axis – either level or laterality. While WSSS is a rare occurrence when examining all spinal surgeries, 50% of spine surgeons report conducting a WSSS in their career. Many institutions have released protocol changes to minimize the likelihood of having a WSSS. Our institution experienced fifteen WSSS incidents between 2008 and 2019 with thirteen corresponding root cause analyses (RCA) at a run rate of 0.708 WSSS per 1,000 surgeries. Our institution introduced a policy update in 2018 to decrease WSSS. This policy update introduced a secondary verification step by a remote radiologist assessing intraoperative X-rays. The radiologist's role is to validate the appropriateness of the image, meticulously label vertebral levels, and give special attention to anatomical landmarks and fixed surgical instrument(s) to identify the intended surgical level. Following this assessment, the radiologist engages in a secure phone or video chat with the attending surgeon in the operating room to confirm the precise location of the fixed surgical instrument(s). To facilitate an independent determination of the specific spinal level, a two to five-minute time-out is observed. The review must be blinded to the staff surgeon's initial localization and may be done either in person or remotely over a secure phone or video chat. While multiple recommendations to avoid WSSS have been made, there is limited data to understand the effectiveness of those recommendations and policy changes in minimizing WSSS. Therefore, the purpose of this study is to examine the effectiveness of a policy change implemented at the end of 2018. Retrospective Review. N/A N/A All WSSS and prevention strategies utilized at our institution between the implementation of the policy and 2023 were reviewed, and all corresponding WSSS-related RCAs were collected from institutional records. An analysis of these reports was conducted. A chi-square test was utilized to analyze the significance of the policy update in reducing WSSS. A p-value < 0.05 was considered statistically significant. Prior to the policy change, fifteen WSSS occurred at this institution with a WSSS run rate of 0.708 WSSS per 1,000 surgeries. After the implementation of the policy fr