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Medical Error Avoidance in Intraoperative Neurophysiological Monitoring: The Communication Imperative

Skinner, Stan*; Holdefer, Robert; McAuliffe, John J.; Sala, Francesco§

Journal of Clinical Neurophysiology: November 2017 - Volume 34 - Issue 6 - p 477–483
doi: 10.1097/WNP.0000000000000419
Review Article

Summary: Error avoidance in medicine follows similar rules that apply within the design and operation of other complex systems. The error-reduction concepts that best fit the conduct of testing during intraoperative neuromonitoring are forgiving design (reversibility of signal loss to avoid/prevent injury) and system redundancy (reduction of false reports by the multiplication of the error rate of tests independently assessing the same structure). However, error reduction in intraoperative neuromonitoring is complicated by the dichotomous roles (and biases) of the neurophysiologist (test recording and interpretation) and surgeon (intervention). This “interventional cascade” can be given as follows: test → interpretation → communication → intervention → outcome. Observational and controlled trials within operating rooms demonstrate that optimized communication, collaboration, and situational awareness result in fewer errors. Well-functioning operating room collaboration depends on familiarity and trust among colleagues. Checklists represent one method to initially enhance communication and avoid obvious errors. All intraoperative neuromonitoring supervisors should strive to use sufficient means to secure situational awareness and trusted communication/collaboration. Face-to-face audiovisual teleconnections may help repair deficiencies when a particular practice model disallows personal operating room availability. All supervising intraoperative neurophysiologists need to reject an insular or deferential or distant mindset.

*Department of Intraoperative Neurophysiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, U.S.A.;

Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington, U.S.A.;

Department of Anesthesia, Cincinnati Children's Hospital, Medical Center, The University of Cincinnati, Cincinnati, Ohio, U.S.A.; and

§Section of Neurosurgery, Department of Neurological Sciences and Movement, University Hospital, University of Verona, Verona, Italy.

Address correspondence and reprint requests to Stan Skinner, MD, Abbott Northwestern Hospital, 800 E. 28th St, Minneapolis, MN 55407, U.S.A.; e-mail:

The authors have no funding or conflicts of interest to disclose.

© 2017 by the American Clinical Neurophysiology Society