Wrong level spine surgeries!

[mmglobal]

Originally posted without citation by Beamer at Braintalk.

Found on: Beth Israel Deaconess admits mishandling three spine operations - The Boston Globe


Beth Israel erred in 3 spinal operations

Vertebrae mix-ups spur new procedures
By Liz Kowalczyk
Globe Staff / December 24, 2010

Surgeons at Beth Israel Deaconess Medical Center operated on the wrong location on three patients who underwent spine surgery since September, despite taking recommended steps to prevent such errors, prompting federal and state health inspectors to cite the hospital for problems in its surgical service.

In all three cases, the surgeons apparently miscounted the patient’s vertebrae and operated on a vertebra directly above or below the diseased segment, said Dr. Kenneth Sands, senior vice president of health care quality at the Boston hospital.

He declined to identify the surgeons — one of whom operated on two of the patients — but he said both are experienced and had followed standard procedures in the operating room, such as taking a “time out’’ to verify the type and location of the surgery.

’’Wrong-level’’ spine surgery is one of the most common types of surgical errors, partly because the 33 vertebrae appear remarkably similar. Each vertebra is little more than an inch tall, with only a small separation between the bony structures.

Still, between 2006 and 2008, just 11 spine surgery errors were reported to the state, making Beth Israel’s three errors in two months unusual.

Sands attributed the three recent cases to human error and said the hospital could not find a connection among them. Since October, when the third error occurred, the hospital has improved its procedures and informed investigators of the changes, he said.

“It is really strange, and we don’t have an answer as to why these happened’’ around the same time, Sands said. Even while following the appropriate steps, he said, “it’s still possible to make a human error.’’

Doctors discovered two of the errors by reviewing postsurgical X-rays after the patients complained of continuing back pain. Those two patients had second surgeries on the correct vertebrae. The third patient’s back pain got better, although the surgeon had operated on the wrong location. That error was recognized during routine postoperative X-rays.

Sands said none of the three patients suffered harmful side effects as a result of the mistaken surgery.

But Andrew C. Meyer Jr., a lawyer representing one of the patients, said that is not true for his client, a 37-year-old woman who underwent surgery to remove herniated disc material at the end of September. She then underwent a second discectomy at the hospital after doctors noticed the error.

The client, who did not want to be identified, has limited mobility as a result of the error, he said.

“Every time you have back surgery, scar tissue develops,’’ Meyer said. “Having to have a second surgery means there is going to be even more scar tissue,’’ which reduces flexibility, he said. He added that his client suffered other complications in the surgery and still experiences pain.

In a Beth Israel Deaconess report that Meyer provided to the Globe, the hospital’s patient safety coordinator said the neurosurgeon in the case and the fellow assisting him had different understandings of how to count and mark the correct vertebrae.

“The neurosurgeon did not recheck the location of the clamp because he thought he and the fellow were using the same reference point,’’ the report said. “When the fellow removed the clamp to proceed with the discectomy, this placed him above the level that was intended.’’

The hospital reported the errors to the state Department of Public Health, which conducted an onsite investigation. The department’s report is not public until the hospital submits a plan of correction, which is due Jan. 7.

Federal inspectors also reviewed the cases, because they coincidentally conducted a routine inspection of the hospital last month.

Beth Israel Deaconess executives said that state and federal authorities found ‘’deficiencies,’’ but that the hospital has already made improvements, including hiring an outside expert to review spine surgery procedures, and adopting a checklist developed by New England Baptist Hospital to help surgeons mark the correct vertebrae during surgery.

A previous Globe review of surgical errors found that Massachusetts surgeons operated in the wrong location on patients 38 times between 2006 and 2008; the 11 botched spine surgeries were the largest category of mishandled operations. New England Baptist accounted for four of the 11 spine operations. In all four cases, the patients came in to have vertebrae fused, and vertebra either directly above or below the diseased bone were operated on instead.

Despite intense efforts by many hospitals to stop wrong-site surgery and wrong-patient operations, the problems persist.

A study published earlier this year in the Archives of Surgery found 107 wrong-site and 25 wrong-patient surgeries in Colorado over a 6 1/2-year period.

Most insurers will not pay for these types of errors now, and Beth Israel Deaconess executives said they did not bill the patients’ insurance companies for the faulty back operations.

[dshobbies]

This proves that doctors are people. While most of us have erasers, they do not. Please choose your doctors carefully. You usually have 1 chance to get it right!!!!!

This message is intended for those of you who think your doctor can't make a mistake in either a diagnosis or recommended procedure.

[dridobits]

This is scary as this was one of the main places I was thinking about doing my surgery. I always write something on my body in a sharpee before surgery.

[AnnOdom]

They should get an x-ray in surgery, with a needle inserted in the lamina of the vertebra they are going to work on. Then they can look at the film, and make sure they are at the correct level. The crazy neurosurgeon I worked with many years ago always did this, to make sure he had the clamp on the correct level. But, it's always good to mark the correct side, which Dr. Ramos's P.A. did, as there have been lots of cases of wrong-sided surgery that were horrible~~~like amputating the wrong limb

[mmglobal]

Several years ago, I was with a client who was going in for a lumbar revision surgery at a major American hospital with a leading spine surgeon. His lowest lumbar level was already fused and he was having surgery at the level above, based on discography results.

Looking at the xrays, it seemed that L5-S1 was fused. Per the discography results, L4-5 was going to get ADR. While he was going through the consenting process, I was reading his reports. This patient had a ‘transitional segment’. He had a 6th lumbar vertebra. I had noticed that references his spine were not consistent. In some cases, they referred to the fused level as L5-S1. In some cases, it was referred to as L6-S1. Some referred to the next level as L4-L5, while others referred to it as L5-L6. Amazingly, not only were different reports inconsistent, but the discography report was inconsistent! In some places, it referred correctly to the transitional segment, while in other places, it incorrectly ignored that fact and mislabeled the levels.

I flagged this to the nurse that was consenting the patient and asked if the surgery that was supposed to be on L4-5 was going to be on the real L4-L5, or if it was supposed to be on L5-L6 (which looks like L4-5 to everyone looking at the imaging. Are they starting at the sacrum and numbering upwards? Are they starting at T12 and numbering downwards? The nurse was uncertain, but assured me that the surgeon knew what he was doing. I insisted that I speak to the doctor before the surgery started. This was inconvenient and the staff was clearly miffed that I was slowing things down.

When the surgeon came out, he hadn’t noticed the inconsistent references to the levels and was unsure which disc was flagged as the painful one. Everything was held in limbo while they tried to reach the doctor who performed the discography. I took a while because they had to get him out of a surgery. (He was an anesthesiologist.) Fortunately, he remembered the procedure and verified that while the report indicated that L4-5 was the painful level, it was really L5-L6.

We’ll never know if they would have performed the surgery on the correct level. Had they assumed that L4-5 was the 2nd level up, they would have been correct. Had they correctly started numbering down from T12 and assumed that the discography report was correct, the surgery would have been performed at the wrong level. (Since the discography report mentioned the transitional segment, I think the error is more likely, but we’ll never know.)

It’s especially easy to operate on the wrong level if there is a transitional segment. That may be a lumbarized sacral vertebra (creating an L6-S1 disc) or a sacralized lumbar vertebra (L4-S1 disc). In papers I’ve seen presented at the conferences, this may be as common as in 17% of spine patients. However, it’s only a potential problem if there are multiple degenerated discs and it’s not obvious from the imaging which ones are to be operated on.

Mark

[jsewell]

Boy that patient is so lucky you were there for them. Often when i went for ESI the permission slep would be wrong. As i have problems in all 3 areas and they are so used to doing lumbar , that was typed in there a lot. I had the nurses call my surgeon (they decided to actually) as i would not sign for the wrong level. My doc always came in and marked my back in the right place, but often would ask me which area i wanted him to do that day. He always gave me like 6 or 8 AT A TIME dividing the medication into smaller doses and changing the meds so the exact area did not have to be marked.

It would be just awful to have the wrong level operated on.
judy

[lyssie]

I am not too sure but this may be a different case from most on this forum but I initially was not fused low enough (my initial fusion was T11-L3, and my scoliotic cobb angle goes down to L4) but the surgeon I believe wanted to saviour some mobility and flexibility within my spine. And only fused me to L3. I know this isn't really 'wrong level' but wanted to add that in

Lyssie

[jsewell]

Lyssie, same happened to me. When i had my T2 thru L2 surgery he was trying to save some motion for me. Then i fractured pretty quickly so a year later i was fused from L2 thru L4. Then more problems and i was just fused and more fractures fixed from L4-l5. I think he is not doing the last one so i get some little bit of motion. I really have to admit, i have not noticed any loss of motion from the lower ones. I guess i was already trying not to move that way do to pain.
I forgot are you in pain management. It kind of helps
Judy

[vnf]

?? Was this a bad translation????