Groucho Marx said it best, "A child of five would understand this. Send someone to fetch a child of five." Thanks to one of our loyal bloggers, TSB finally became motivated to post on last week's report by the Boston Globe's Liz Kowalczyk, regarding neurosurgeons at Beth Israel Deaconess (BID) that had operated on the wrong levels during spine surgery on three patients. Seems like BID is having a difficult time digging out of this negative publicity. Unfortunately for the patients, the surgeons apparently miscounted while identifying the levels to be operated on, and proceeded to operate on the adjacent level above or below the affected vertebral bodies.
Dr. Kenneth Sands, Senior Vice President of Health Care Quality at the Boston hospital, declined to identify the surgeons, but he did add that "both surgeons were experienced," thank God, and had taken the "time out" to verify the type and location of the surgery. Could these surgeons be members of the Louisville 5 spine basketball team? They took a time out and diagrammed a play so that they could execute the procedure. No one ever said that surgeons were good at counting, it's not like we're asking them to design an algorithm so that we could manipulate some financial instrument. TSB assumes that by time one gets out of residency most spine surgeons have learned how to count to seven, count to twelve, or count to five.
What's even more entertaining is when Dr. Sands attributes this occurrence to pilot error. Can anyone imagine what would happen if an airline pilot miscalculated the length of a runway, or, missed the runway on approach, or, decided to land on the runaway for departing flights? We would have what is commonly known as FUBAR. Fortunately for these patients, by the sounds of this report, these were not fusion procedures. But what really jumps out in this report is that one patient's back pain had gotten better even though the surgeon operated on the wrong level. Could that procedure have resulted in a placebo effect? By decompressing the adjacent level the patient supposedly felt better. But it gets better.
The neurosurgeon and the fellow assisting him had a difference in understanding how to count and mark the correct vertebrae. Let's see one comes before two, two comes before three, etc.... The hospital reported that state and federal authorities had found deficiencies and that hospital administrators are addressing the problem by hiring an arithmetic teacher, while adopting a checklist developed by NE Baptist Hospital to help surgeons mark the correct vertebral body.
Considering that most insurance companies will not pay for these trial run procedures, BID administrators were kind enough not to bill the patients and will be sending them to an all expense paid vacation in Barbados, of course right after their attorney's get through suing the hospital. You got to love America, it doesn't get any better than this. TSB wants to know, is this act coming to your local town?
Saw an ACDF on the wrong level once.
ReplyDeleteOn the surface, this is an appalling story. However, wrong-level surgeries are more "common" that one might assume.
ReplyDeleteA study on this topic was completed in 2008, via questionnaire to all NASS memberships at the time - 3,505, and published in SPINE . It estimated/extrapolated that one out of every two surgeons will operate on a wrong level in their career. Put more bluntly, 207 of the 418 respondents reported this making mistake AT LEAST ONCE, yikes.
** http://tinyurl.com/27wdeor
why barbados?
ReplyDeleteWhat does operating on the wrong level have to do with the Leatherman group?
ReplyDeleteActually TSB, a very common cause for wrong level surgery is not miscounting, but having the wrong patient's MRI up on the viewing board in the OR. Happens ALL the time. So to all you good reps out there, you might want to double check that name - it may earn you a gold star.
ReplyDeleteWas in a case once where the patient had a 2 level decompression done but as actually supposed to be in the hospital to have a hip replacement!!!
ReplyDeleteWhooopsie,,,
Some people have 6 lumbar vertebrae which can account for miscounting if everyone has not agreed on a numbering system in advance. Even the radiology reports on these patients can "mix" them up, if it's not standardized.
ReplyDeleteEnough with the "they're not smart enough." We know that is not true, and nobody was there to know the situation. It should not happen, thus a "never event", but it did, and "never events" will continue to happen so far as I can imagine, hopefully with smaller and smaller frequencies.
I can understand a misjudgement in the upper/mid thoracic spine, where it is often difficult to identify the correct level through flouro or xray. I cannot, however, excuse a miscalculation in the cervical or lumbar regions, where there are numerous landmarks (ribs, sacrum, etc) to count towards and away from. This is just pure carelessness on these "experienced" surgeons...maybe it's time they re-took their boards....or 3rd grade math?
ReplyDeleteDon't forget that even the last person in every graduating class of medical school is called "Doctor",,
ReplyDeleteI was hoping someone else would catch it but...11:56, if the surgeon is basing his surgical level on a pre-op MRI and not an intra-op lateral fluoro, you may have other issues.
ReplyDeleteIt happens..... And the people that it happens to are not idiots nor incompetent in most cases. Many reasons this can happen, none of which are acceptable but thats what malpractice is for if a patient decides to exercise it.
ReplyDelete12/27 11:56 commented about good reps looking at pt image. Ironically I was reprimanded by the hospital for looking at the pt's MRI as a case was starting. This occurred after I pointed out to the OR staff that they had the wrong pt info on the screen (same name, diff DOB). I had worked up the pt with the MD preop and knew we were working on a 63 yo vs the 33 yo they had on the screen. Glad to see the hospital policy is protecting the pt.
ReplyDeleteHalf of the doctors in this country graduated in the bottom half of their class.
ReplyDeleteIf you ask me, I think one of the major causes of wrong-site surgeries is the lack of attention surgeons allocate to the TIME OUT. Between 75 and 80% of the surgeons I have worked with over the years simply blow this off as if it were no big deal. Well, it is a big deal, and I have seen many a surgeon make mistakes by ignoring it.
ReplyDeleteSo, what's the solution? I say we make the surgeon's do the timeout on their own from memory. This would ensure that the surgeon knows the precise procedure he or she is about to perform and on whom it will be performed. If the surgeon can't complete such a simple task, they are probably not qualified or informed well-enough to perform the procedure anyway.
746 - Good luck finding an orthopod or neurosurgeon that graduated at the 50th perc. or lower in their undergrads. Last I check still amongst the most competitive plans for after undergrad. Also among the most competitive residencies, so 50th perc. or lower in your med school would be an outlier. Good to know so many reps think this is a piece of cake.
ReplyDeleteAlso, again 6 lumbar vert. one person counts from the sacrum up, one from the last rib down, there is your mistake. Agree the timeout is underrated.
There is Level 1 evidence that looks at this specific issue. The BRYAN Cervical Disc from Medtronic had a 2% wrong-level surgery rate (out of 500 patients, that is 10 patients got operated on the wrong level). Now, not all disc studies have shown this, but it does happen.
ReplyDeleteWhy would anyone count from the sacrum up? First year reps know about lumbarized sacral vertebrae, and sacralized lumbar vertebrae, shouldn't a surgeon?
ReplyDeleteHow about T12's without ribs? What's the difference? Or L1s with "riblets" that look like ribs?
ReplyDeleteEasy to throw stones guys. You watch it enough and you think you can do it. Forgetting everything else that it took to get there. No different from surgeons looking at successful business ventures and figuring they should get into it.
And for all those that criticize surgeons for using single companies - ALL YOUR STUFF IS THE SAME! Makes the case go much smoother if everyone in the room is familiar with the set rather than making them learn this and that.
Hell, I remember watching on ER where the use of the 'Safe Surgery Checklist' both brought ire from the MD *AND* saved a life. Fiction, true, but seems a topic real enough for the producers to heave it into the light...
ReplyDeleteTAKE THE FRACKIN' TIME OUT!
C'mon doc, be honest...what is the prevalence of L1's with riblets, or T12's without ribs? While we all know that anatomy is not 100% consistent from one person to another, there are protocols that account for the statistical anomalies.
ReplyDeleteAre you saying that you start counting at C1 for a L3-L4 procedure to make sure you are operating on the correct level? My guess is that you identify the level and assign a label (eg: L3-L4,) which by your own admission is somewhat arbitrary and possibly incorrect, and match the intraoperative images with the preop image to make sure you are approaching the correct level. It is the attention to the plan, and taking the time to verify name, age, etc. that leads to operating at the correct level, not your pedigree or fellowship training, unless that is where you learned to be thorough.
I get what you are saying, but if it is "everything else that it took to get there," that makes you the MD, and the rep the rep, then why do these types of mistakes happen? You make it sound like your training makes you infallible, yet I see day in and day out surgeons cut corners, go off technique and cavalierly compromise the process that we are ALL part of. It is somewhat ironic that the surgeons tout their training and "what it took to get there," but when something goes wrong, they look to the rep to creatively get them out of trouble, or blame the rep/company for their lack of skill or planning.
I absolutely respect the education, and training that surgeons go through, as long as it is coupled with humility and respect for the capabilities of their support network. I have worked with surgeons from both extremes over the years (~15 years,) and I know to whom I would send my loved ones.
It is rare, but there are docs whose first instinct is to ask what they did wrong, rather than throw an instrument across the room with the decree that it is a peice of crap.
Point is that the prior rep posted something to the effect that "everyone knows about sacralized lumbar vert" as if the physicians in question did not, and were less educated than them. In any instance the numbering should be standardized before anyone steps foot in the or. The rep has nothing to do with wrong site surgery. The team of the fellow and attending make the call, everyone in the room should look and speak up regarding any question. This is the extension of the timeout that many surgeons are reluctant to accept. We have a lot to learn from the airline industry in terms of root cause analysis. How many cockpits have music blaring? And 5 extra people milling about - maybe wearing dirty clothes?
ReplyDeleteMistakes like this happen because NOBODY is infallible. To think because you can, in retrospect and without seeing the imaging, be in the same situation and NOT make the mistake implies that you are the infallible one. I check the spot films like I have OCD. Lots of grey areas in the diagnosis, the treatments, the mistakes.
Did the BID guys blame the rep? Not sure where you get that. As everyone who reads this site knows, the surgeeon that acts like a neaderthal in the or and looks to blame OTHER people is often not comfortable with what they've done, either diagnostically or technically, to put them in the situation where they lose their cool. "No Blame Technique" is the only way to fix these types of mistakes efficiently. Look for the causes and possible fixes and spend less time trying to blame anyone. "It's the rep's fault" - right, not the tech that didn't load it correctly? or the surgeon that didn't recognize that it was loaded correctly? Or the fact that a different set is being used because CPD screwed up something processing the regular set? Let the patient and their lawyer figure out what's malpractice.
BTW, I label the vertebrae with a marker, so nothing is "arbitrary" - that would eventually lead to a mistake if I do enough cases.
MM, are you sleeping on the job, or is this just getting too pedestrian? From the NYT on Monday: "2 Senators Raise Questions on Use of Medtronic Device" A highlight: "The study concluded, in glowing terms, that Hydrosorb might be “ideally suited” to spinal use. Medtronic has also made payments for consultancy or other services to the three doctors — Timothy R. Kuklo, Michael K. Rosner and David W. Polly Jr., all then with Walter Reed.
ReplyDeleteSix years after the implants, however, Hydrosorb has still not been approved for that use. The senators expressed safety concerns"
I have worked in the OR as a nurse for 15 years with all types of spine guys, as well as others. Unfortunately, this kind of thing happens...what amazes me about the BID deal is that it seems it wasn't caught in surgery and corrected. If one doesn't find the disease wouldn't you spend time second guessing what level you were at?
ReplyDeleteTSB is working on the Year In Review. Will check it out. As for Polly and Kuklo that is old news and has been reported on in the past, please reference Archives. Thnx
ReplyDeleteI'm saddened by the stones being thrown between surgeon and rep. When everyone else is questioning the value of spine surgery, lets not forget that we're on the same side.
ReplyDeleteOf course it's not the reps responsibility! However, a rep that finds a way to play an active role in a case, CAN add value, and likely will have a good career in spine. Shame on the reps that question a surgeon's intellect, as we have no clue how many variables a surgeon is considering while operating.
I also feel sorry for the surgeons who view industry as the enemy. The relationship can be extremely beneficial for the surgeon if they find companies/reps they can rely on.
Lets focus our vitriol on Washington DC and insurance companies.
Lastly, while I'm sure this only a fraction of the cases... The times that I have seen wrong levels operated on have been multi-level cases where the pathologic levels WERE properly localized. At some point in the case, the surgeon's orientation shifts cranial or caudal and further decompression ensues.
I have seen very experiences surgeons use a skin marker to color directly on bone to mark the operative levels.
1:41
ReplyDeleteI agree with your statement, "let's focus our vitriol on Washington DC and the Insurance Industry, sadly, it's the people that go to work every day attempting to improve the patient's quality of life that end up being pitted against one another. Disorganized democracy never beats organized corporations with tremendous amounts of capital to buy our "esteemed" Senators influence. To paraphrase an old politician, "there are only two things that are important, money is one, and I can't remember the other."
More spine coverage (similar to WSJ) from Bloomberg
ReplyDeletehttp://noir.bloomberg.com/apps/news?pid=20601109&sid=akgS7Fb6dBcg&pos=10
Medtronic has created a monster in Saint Paul(and a few other centers we all know). MDT needs to rein these guys in before the whole industry is buried under a mountain of bad press. Enough is enough.
ReplyDeleteWhen CMS and the private payors severely restrict fusion reimbursement, MDT and the pigs feeding at their trough will have no one but themselves to blame.