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Incidence of Neurosurgical Wrong-Site Surgery Before and After Implementation of the Universal Protocol

Vachhani, Jay A. MD; Klopfenstein, Jeffrey D. MD

doi: 10.1227/NEU.0b013e318283c9ea
Research-Human-Clinical Studies: Editor's Choice
Editor's Choice

BACKGROUND: Although exceedingly rare, wrong-site surgery (WSS) remains a persistent problem in the United States. The incidence is thought to be 2 to 3 per 10 000 craniotomies and about 6 to 14 per 10 000 spine surgeries. In July 2004, the Joint Commission mandated the Universal Protocol (UP) for all accredited hospitals.

OBJECTIVE: To assess the effect of UP implementation on the incidence of neurosurgical WSS at the University of Illinois College of Medicine at Peoria/Illinois Neurological Institute.

METHODS: The Morbidity and Mortality Database in the Department of Neurosurgery was reviewed to identify all recorded cases of WSS since 1999. This was compared with the total operative load (excluding endovascular procedures) of all attending neurosurgeons to determine the incidence of overall WSS. A comparison was then made between the incidences before and after UP implementation.

RESULTS: Fifteen WSS events were found with an overall incidence of 0.07% and Poisson 95% confidence interval of 8.4 to 25. All but one of these were wrong-level spine surgeries (14/15). There was only 1 recorded case of wrong-side surgery and this occurred after implementation of the UP. A statistically greater number of WSS events occurred before (n = 12) in comparison with after (n = 3) UP implementation (P < .001).

CONCLUSION: A statistically significant reduction in overall WSS was seen after implementation of the UP. This reduction can be attributed to less frequent wrong-level spine surgery. There was no case of wrong procedure or patient surgery and the 1 case of wrong-side surgery occurred after UP implementation.

ABBREVIATIONS: JC, Joint Commission

UP, Universal Protocol

WSS, wrong-site surgery

Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine in Peoria, Peoria, Illinois

Correspondence: Jay A. Vachhani, MD, Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine in Peoria, 530 NE Glen Oak Ave, Peoria, IL 61637. E-mail:

Received May 24, 2012

Accepted December 04, 2012

Copyright © by the Congress of Neurological Surgeons