SPINE Volume 35, Number 9S, pp S28 –S36 ©2010, Lippincott Williams & Wilkins Avoiding Wrong Site Surgery A Systematic Review John DeVine, MD,* Norman Chutkan, MD,† Daniel C. Norvell, PhD,‡ and Joseph R. Dettori, PhD‡ Study Design. Systematic review. Objective. To report the incidence and causes of wrong site surgery and determine what preoperative measures are effective in preventing wrong site surgery. Summary of Background Data. From 1995 to 2005, the Joint Commission (JC) sentinel event statistics database ranked wrong site surgery as the second most frequently reported event with 455 of 3548 sentinel events (12.8%). Although the event seems to be rare, the incidence of these complications has been difficult to measure and quantify. The implications for wrong site surgery go be- yond the effects to the patient. Such an event has pro- found medical, legal, social, and emotional implications. Methods. A systematic review of the English language literature was undertaken for articles published between 1990 and December 2008. Electronic databases and refer- ence lists of key articles were searched to identify the articles defining wrong site surgery and reporting wrong site events. Two independent reviewers assessed the level of evidence quality using the Grading of Recommen- dations Assessment, Development, and Evaluation crite- ria and disagreements were resolved by consensus. Results. The estimated rate of wrong site surgery var- ies widely ranging from 0.09 to 4.5 per 10,000 surgeries performed. There is no literature to substantiate the ef- fectiveness of the current JC Universal Protocol in de- creasing the rate of wrong site, wrong level surgery. Conclusion. Wrong site surgery may be preventable. We suggest that the North American Spine Society and JC checklists are insufficient on their own to minimize this complication. Therefore, in addition to these protocols, we recommend intraoperative imaging after exposure- and marking of a fixed anatomic structure. This imaging should be compared with routine preoperative studies to determine the correct site for spine surgery. Key words: wrong site, wrong level, wrong patient, wrong side. Spine 2010;35:S28 –S36 The potential complications encountered during spinal surgery are varied and can occur during both the intra- operative and the postoperative period. Although strat- egies are used to decrease the risk of these potential com- plications, the majority are not preventable. For example, it is unrealistic to think that the risk of infection will ever be eliminated, despite sterile technique and an- tibiotics used during the perioperative period. It is unre- alistic to think the risk of deep venous thrombosis will ever be eliminated, despite the use of mechanical DVT prophylaxis and early mobilization. On the contrary, wrong level or wrong side surgery may be preventable. The JC defines wrong site surgery as any surgery per- formed on the wrong site or patient or performance of the wrong procedure. 1 Wrong site surgery is a broad term that encompasses all surgical procedures performed on the wrong body part or wrong patient. The following are more specific descriptions of wrong site surgery. 2 Wrong level or part surgery is a surgical procedure per- formed at the correct site but at the wrong level or part of the operative field. For example, performing a lumbar laminectomy on an unintended intervertebral level im- mediately adjacent to an intervertebral level with identi- fied pathology can be considered as wrong level or part surgery. Wrong patient surgery is a misidentification of the patient leading to a procedure performed on the wrong patient. Wrong side surgery is a surgical proce- dure that involves operating on the wrong extremity or wrong side of the body. Wrong level exposure occurs when a level other than the intended level of surgery is exposed; however, it does not necessarily mean that sur- gery was performed at the incorrect level (Table 1). From 1995 to 2005, the JC sentinel event statistics database ranked wrong site surgery as the second most frequently reported event with 455 of 3548 sentinel events (12.8%). Although the event seems to be rare, the incidence of these complications has been difficult to measure and quantify. The implications for wrong site surgery go beyond the effects to the patient. Such an event has profound medical, legal, social, and emotional implications. 3 The American Academy of Orthopedic Surgeons first addressed the issue in an advisory state- ment issued in 1997, recommending that surgeons put their initials on the operation site. 4 The North American Spine Society (NASS) developed the “Sign, Mark and Radiograph” program in 2001, consisting of a checklist From the *Orthopedic Service, Department of Surgery, Eisenhower Army Medical Center, Ft. Gordon, GA; †Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, GA; and ‡Spectrum Research Inc., Tacoma, WA. The manuscript submitted does not contain information about medical device(s)/drug(s). Supported by AOSpine North America. Analytic support for this work was provided by Spectrum Research, Inc. with funding from AOSpine North America. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. J.D. was a primary author and participated in data analysis, introduc- tion, discussion, clinical recommendations, and manuscript prepara- tion; N.C. was a second author and participated in data analysis, in- troduction, discussion, clinical recommendations, and manuscript editing; D.C.N. participated in systematic searches, pooled summaries of the data, tables, and manuscript review; and J.R.D. participated in systematic searches, pooled summaries of the data, tables, and manu- script review. Address correspondence and reprint requests to John DeVine, MD, Orthopedic Service, Department of Surgery, Eisenhower Army Medi- cal Center, 300 E. Hospital Road, Ft. Gordon, GA 30809. E-mail: john-devine@comcast.net S28