Practice of Medicine

Claims Lesson

Recruit Claims Her Military Career Cut Short by Wrong-Site Surgery

February 28, 2014

The Case:

This patient injured her back during training. Thereafter, she was unable to perform all of her job duties. She was referred to an orthopedic surgeon who performed a L4-5 laminotomy and diskectomy due to disk herniation. Although the surgeon had been hesitant to perform the diskectomy, the patient was adamant that she did not want fusion surgery, as she felt it would end her military career.

Despite therapy, exercise, and epidural injections, the patient continued to have moderate back pain and sciatica. She returned to the surgeon eight months later. The surgeon explained that she was a candidate for spinal fusion or artificial disk replacement surgery. A repeat MRI did not show a recurrent disk herniation which meant that diskogenic pain was the most likely diagnosis. The surgeon explained that the failure rate for these operations is in the 20-25% range. The other risks of the surgery were explained in detail. The patient had done her own research, as well, and was ready to “participate in whatever was necessary”. The patient was primarily interested in disk replacement surgery.

The disk replacement procedure involved a two part procedure. The general surgeon nicked the patient’s vena cava during the anterior approach and the operative area had to be packed. When the orthopedic surgeon arrived in the operating room for the second part of the procedure, he took radiographic localization to confirm they were at the L4-5 level. But, shortly thereafter, he determined that he was at L5-S1, the wrong level. He stopped the procedure and tried to mobilize the vessels to get exposure to L4-5. This was not possible because the bifurcation of the iliac vein was just inferior to the L4-5 level. The bifurcation is usually just above the area. Initially, they were going to attempt disk replacement at both levels, but once they realized they could not make an anterior approach to L4-5, the orthopedic surgeon elected to perform an anterior lumbar interbody fusion at L5-S1. The patient was subsequently discharged from the military with a 20% medical impairment, but continued to work. She complained of chronic pain and limited mobility.

In her lawsuit against the orthopedic surgeon, the plaintiff alleged that the orthopedic surgeon failed to perform a disk replacement at L4-5 for which she had given informed consent, negligently failed to obtain informed consent for disk removal at L5-S1, negligently failed to identify the location of L4-5, and negligently removed the L5-S1 disk. As a result, the plaintiff alleged that she had suffered a permanent back injury and interference with her ability to move and ambulate. She contended that her back condition was made worse. The lawsuit was settled for a moderate amount of money.

Risk Management Commentary:

How might this orthopedic surgeon have prevented the wrong-site surgery?

  • The orthopedic surgeon testified that had he done fluoroscopy immediately prior to the operation at L5-S1, he probably would have realized he was at the wrong level.
  • One of the defense experts indicted that disk replacement surgery was a fairly new procedure in the United States at the time it was performed on this patient. In order to do the disk replacement, he explained one must use an anterior approach. He stated that you are performing two operations:   the exposure of the area by a vascular surgeon and then the actual orthopedic surgery at the disk space. This expert believed that a laminectomy would have been more effective and the surgeon would have been less likely to have operated at the wrong level.

“Wrong-site surgery is the sentinel event most frequently reported to The Joint Commission,” said Bradford Currier, M.D., Professor of Orthopedics at the Mayo Clinic in Rochester, Minnesota. during a presentation at the 2012 Cervical Spine Research Society Annual Meeting.[i]

According to Dr. Currier, “approximately 30 percent of wrong-site surgeries reported in Minnesota are wrong-level spine procedures“.  Dr. Currier also stated that, “despite its frequency and substantial health and medico legal ramifications, wrong-site spine surgery (WSSS) is poorly defined and consequently has ambiguous and variable reporting requirements.”

There are several factors inherent to spine surgery that increase the risk of WSSS compared with other types of surgery. Not only can a surgeon potentially operate on the wrong side of the spine or the wrong level, but there are unique issues related to spinal localization that can be challenging for even the most experienced clinician. Strategies to avoid wrong-site spinal surgery are discussed in the article, Strategies to avoid wrong-site surgery during spinal procedures by Wesley Hsu, MD et al[ii]. The authors provide a detailed review of the following areas:

  • Preoperative verification of surgery
  • Intraoperative localization
  • Localization in the Cervical Spine
  • Localization in the Thoracic Spine
  • Localization in the Lumbar Spine
  • Prevention of WSSS using 3D Intraoperative Imaging

Wrong-site surgery should be viewed as a preventable complication. Verification of the intended surgical site preoperatively is critical; standardized checklists can help facilitate this process. Recognition of the unique challenges in spinal localization should be acknowledged and there are strategies discussed in the literature that are safe and easy to implement to help to ensure accurate intraoperative localization.

Authors: MagMutual Patient Safety Institute: Mary Gregg, MD President, Laura Martinez, BSN, RN, MS, CPHRM, FASHRM, VP Risk Management, Georgette Samaritan, RN, BSN CPHRM, Senior Risk Management Consultant

MAG Mutual Risk Management and Patient Safety Consultants invite our policyholders’ questions. If you wish to discuss information presented in this article, or have other questions please call us at 1-800-282-4882 and ask for Risk Management.

[i]Wrong-Site Spine Surgery: An Underreported Problem?

[ii] Strategies to avoid wrong-site surgery during spinal proceduresNeurosurgical Focus. 2011 Oct; 31(4):E5. doi: 10.3171/2011.7.FOCUS1166.




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