Vertebrae mix-ups spur new procedures
By Liz Kowalczyk
Globe Staff / December 24, 2010
Surgeons at Beth Israel Deaconess Medical Center operated on the wrong location on three patients who underwent spine surgery since September, despite taking recommended steps to prevent such errors, prompting federal and state health inspectors to cite the hospital for problems in its surgical service.
In all three cases, the surgeons apparently miscounted the patient’s vertebrae and operated on a vertebra directly above or below the diseased segment, said Dr. Kenneth Sands, senior vice president of health care quality at the Boston hospital.
He declined to identify the surgeons — one of whom operated on two of the patients — but he said both are experienced and had followed standard procedures in the operating room, such as taking a "time out" to verify the type and location of the surgery.
"Wrong-level" spine surgery is one of the most common types of surgical errors, partly because the 33 vertebrae appear remarkably similar. Each vertebra is little more than an inch tall, with only a small separation between the bony structures.
Still, between 2006 and 2008, just 11 spine surgery errors were reported to the state, making Beth Israel’s three errors in two months unusual.
Sands attributed the three recent cases to human error and said the hospital could not find a connection among them. Since October, when the third error occurred, the hospital has improved its procedures and informed investigators of the changes, he said.
“It is really strange, and we don’t have an answer as to why these happened" around the same time, Sands said. Even while following the appropriate steps, he said, “it’s still possible to make a human error."
Doctors discovered two of the errors by reviewing postsurgical X-rays after the patients complained of continuing back pain. Those two patients had second surgeries on the correct vertebrae. The third patient’s back pain got better, although the surgeon had operated on the wrong location. That error was recognized during routine postoperative X-rays.
Sands said none of the three patients suffered harmful side effects as a result of the mistaken surgery.
But Andrew C. Meyer Jr., a lawyer representing one of the patients, said that is not true for his client, a 37-year-old woman who underwent surgery to remove herniated disc material at the end of September. She then underwent a second discectomy at the hospital after doctors noticed the error.
The client, who did not want to be identified, has limited mobility as a result of the error, he said.
“Every time you have back surgery, scar tissue develops," Meyer said. “Having to have a second surgery means there is going to be even more scar tissue," which reduces flexibility, he said. He added that his client suffered other complications in the surgery and still experiences pain.
In a Beth Israel Deaconess report that Meyer provided to the Globe, the hospital’s patient safety coordinator said the neurosurgeon in the case and the fellow assisting him had different understandings of how to count and mark the correct vertebrae.
“The neurosurgeon did not recheck the location of the clamp because he thought he and the fellow were using the same reference point," the report said. “When the fellow removed the clamp to proceed with the discectomy, this placed him above the level that was intended."
The hospital reported the errors to the state Department of Public Health, which conducted an onsite investigation. The department’s report is not public until the hospital submits a plan of correction, which is due Jan. 7.
Federal inspectors also reviewed the cases, because they coincidentally conducted a routine inspection of the hospital last month.
Beth Israel Deaconess executives said that state and federal authorities found "deficiencies," but that the hospital has already made improvements, including hiring an outside expert to review spine surgery procedures, and adopting a checklist developed by New England Baptist Hospital to help surgeons mark the correct vertebrae during surgery.
A previous Globe review of surgical errors found that Massachusetts surgeons operated in the wrong location on patients 38 times between 2006 and 2008; the 11 botched spine surgeries were the largest category of mishandled operations. New England Baptist accounted for four of the 11 spine operations. In all four cases, the patients came in to have vertebrae fused, and vertebra either directly above or below the diseased bone were operated on instead.
Despite intense efforts by many hospitals to stop wrong-site surgery and wrong-patient operations, the problems persist. A study published earlier this year in the Archives of Surgery found 107 wrong-site and 25 wrong-patient surgeries in Colorado over a 6 1/2-year period.
Most insurers will not pay for these types of errors now, and Beth Israel Deaconess executives said they did not bill the patients’ insurance companies for the faulty back operations.
Liz Kowalczyk can be reached at kowalczyk@globe.com.
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