Patient Safety Tip of the Week


November 25, 2008

Wrong-Site Neurosurgery        






The National Patient Safety Agency (UK) has just released a new guidance for neurosurgical teams to avoid wrong side burr holes. This includes the formal guidance and the supporting information. This release comes after identification of at least 15 instances of wrong-sided burr holes or craniotomies in less than a 3-year period. Most of you, of course, remember the press last year about three wrong-site surgeries that occurred at Rhode Island Hospital within a one year period.


So is this a problem that neurosurgery is especially prone to? And is this an increase in occurrence rate?


Well, it is probably not an increase. A national audit in the UK published in 2005 noted that at least 17 cases of wrong-site neurosurgery had been identified in the previous 2 years (Winbush 2005). And an anonymous survey of Canadian neurosurgeons in 2004 estimated the incidence of wrong-site surgery for lumbar spine surgery, cervical discectomies, and craniotomies to be 4.5, 6.8, and 2.2 occurrences per 10,000 operations respectively (Jhawar 2007) and they found those rates were likely stable over a 5-year period. The percentage of wrong-site surgery cases in the Joint Commission Sentinel Event database for neurosurgery was 12-13% from 1995 to 2005 (Croteau 2007), though it dropped in subsequent years.


The anonymous survey by Jhawar et al noted that 25% of all neurosurgeons responding admitted to having cut skin on the wrong side of the head at one point in their careers. Contributing factors for wrong-side craniotomies were emergency nature of the case, after-hours surgery, fatigue, and unusual time pressure to start of complete the case. Other factors included mental distraction, neurological false localizing signs (eg. the dilated pupil being on the “wrong” side), unusual positioning of the patient (either in the OR or in the CT scanner), unusual OR setup, incorrect placement of the images on the viewbox, and others. In 11% of the cases the appropriate imaging studies were not available in the OR.


The neurosurgeons in the Jhawar study noted that standard protocol was breached in 40% of the wrong-side craniotomies and 21% of the wrong-level spinal surgeries.


For wrong-level spinal surgery, contributing factors were more likely related to lack of intraoperative imaging capabilities, poor quality of images, and unusual  patient anatomy.


The Jhawar group also noted that wrong-site surgeries actually tended to occur more often with experienced surgeons, a finding similar to that noted for hand surgeons.


The UK NPSA guidance noted the following challenges as contributing to wrong-side burr holes or craniotomies: need for midline incisions, reliance on imaging, difficulty marking below the hairline, and inability of patients to confirm the appropriate site. But they also found numerous breaches of best practice: lack of site listing on various documents, failure to mark the side of surgery, lack of compliance with pre-operative assessment or final verification, and lack of being challenged or questioned by other operating room staff.


There are a few risk factors relatively unique to neurosurgical patients that may further contribute to wrong-site neurosurgery. By virtue of their pathological condition they may be obtunded or comatose or confused or aphasic so they may be unable to participate in their site verification in a meaningful way. Also, the crossed nature of many of the neurological deficits (eg. right hemisphere-left hemiparesis) may be confusing not only to patients but to staff as well.


The Rhode Island incidents add some other dimensions to the discussion. Rhode Island Hospital had an incident during the summer of 2007 in which a neurosurgeon operated initially on the wrong side of the head in a patient with a subdural hematoma. Apparently in that case a nurse did raise questions about site verification but the surgeon felt he was sure which side the subdural was on (AP/ 2007). The hospital had been undergoing corrective action in conjunction with the Rhode Island Health Department when, in November 2007, another case where surgery began on the wrong side of the head occurred. The latter case involved a procedure for a subdural hematoma that was being performed by the neurosurgery chief resident at the bedside in a neurosurgery ICU. No formal preprocedure site verification had taken place and the nurse attending the procedure was a “travel nurse” who had not been trained on the hospital policy and procedure for preprocedure site verification. The hospital’s corrective efforts after the July 2007 case had been focused on procedures being performed within the operating room and apparently had not yet focused on invasive procedures elsewhere.


The third case had occurred in January 2007 and involved a neurosurgery resident placing a drain on the wrong side of a patient’s head. That procedure also had occurred at the bedside. Though the hospital apparently had a procedure for invasive procedures performed outside the operating room and a form to be completed prior to such procedures, the resident was quoted as saying “he knew about the policy but he had never seen the form or seen anyone use it” (Mello 2007).


The three Rhode Island cases show several of the commonest circumstances or factors predisposing to wrong-site surgery: incomplete availability of all records and images, emergency procedures, not ensuring that all staff understand the safe-surgery verification procedures, and a hierarchical authority gradient.


That a case is being performed on an emergency basis is, of course, no excuse for not performing an appropriate “timeout” and final site verification before commencing with surgery. The 2-3 minutes that would have been spent doing such verification are far less than the time wasted in beginning the cases on the wrong side.


The Rhode Island cases also highlight a very important fact: wrong-site surgery is very common outside the operating room. (In New York we have seen wrong-site incidents with a variety of procedures, most notably bedside procedures such as chest tube insertions). So it is incumbent upon all organizations to give as much attention to safety of procedures out of the OR as in the OR.


The issue of training is critical. All your staff must understand the safe surgery policies and procedures. Many hospitals have a continuous influx of new nurses and residents rotating through various services. Sometimes you have an agency nurse or a “float” resident covering a service for just one or a few nights. It is incumbent upon all hospitals to ensure that they get appropriate orientation and are not unwittingly put in the position where they might do a wrong-site procedure.


The hierarchical/authority gradient issue is one that rears its ugly head in many, if, not most, cases of wrong-site surgery. Undoubtedly, there are some of you reading this and thinking “its that neurosurgeon’s personality!”. We don’t think so. We know lots of neurosurgeons who are meticulous safety-conscious empathetic physicians and such a generalization would be demeaning and unfair. Wrong-site surgery occurs in all specialties. However, the cluster of cases within a department at Rhode Island Hospital does raise another important point. Just as there are “microclimates” in meteorological environments, there are different “cultures of safety” within organizations. Even within an operating room, you have teams that function as units and their culture may be different from that of other OR teams. That is the reason we are not advocates of formal culture of safety assessments. There are several good instruments and tools out there for assessing culture of safety. But applying them organization-wide can provide very misleading results. More often what we see is that a hospital overall may do well on such assessment but there are individual units or departments or other “pockets” in which the culture of safety is less than desirable. And we feel you can learn much more about those “pockets” during your patient safety walkrounds by looking around and asking around.


Our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery” stressed the importance not just of developing policies, procedures and checklists but of auditing the use and success of such procedures and checklists. In that column we noted that all hospitals have policies compatible with the Joint Commission Universal Protocol but very few actually monitor how those policies are used on a day-to-day basis. You can have all the policies in the world but if you do not have a culture of safety the intent of those policies is never guaranteed. So monitor how your actual performance is on both operating room procedures and those done outside the operating room.


The UK NPSA guidance recommends that the side of intended cranial surgery be marked by the surgeon on the side of the forhead (or back of the neck below the hairline for posterior approaches). Such marking ideally is done outside the OR at a time when imaging studies, notes, and the patient consent are available and when the patient or caregiver is able to participate in confirmation of the site marking. The final verification/timeout should take place in the OR immediately prior to anticipated incision. Note that these recommendations follow in general the WHO Safe Surgery Checklist (see our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist”.) The Jhawar paper also stresses that during the timeout immediately prior to the first incision, the other members of the team verify the patient and the surgical site by reviewing the case booking information on the OR schedule, the consent form, and any site marking and the surgeon reviews the imaging studies.


Our comment on imaging studies: It is critical that imaging studies on the patient be available both before and during the surgery. But that is not enough. You need to ensure that the X-ray folder does not contain individual images of other patients. And when the images are placed on the view box, it is critical that attention be paid to ensure that the image is not placed backwards or in other manner that might lead to right-left confusion. We also stress that you need to make sure that the OR does not contain images for any other patients or cases. The practice of bringing images for “all the cases of the day” into the OR is one that will lead you to do wrong site surgery at some point in your career.


See our Patient Safety Tools and Resources page for links to many other great safe site protocols and tools, including the great work that has been done on the topic by organizations like the Pennsylvania Patient Safety Authority and the Joint Commission.





Update: See our September 14, 2010 Patient Safety Tip of the Week “Wrong-Site Craniotomy: Lessons Learned”.







National Patient Safety Agency (UK). New guidance for neurosurgical teams to avoid wrong side burr holes. November 2008

actual guidance

supporting information



AP/ Trail of errors led to 3 wrong brain surgeries. Surgeons' ego at R.I. hospital may have led to carelessness, study says. December 14, 2007



S, Wimbush; S, Shinde; J, Carter National Audit of "Wrong-Site" Neurosurgery. Journal of Neurosurgical Anesthesiology. 2005; 17(3):160-161;jsessionid=JjJKsCPVDMMfsjNLcS3yH6KNGTVQZJKLZ1Vl101nJvKL5qQwFJ2V!-409308177!181195629!8091!-1


Jhawar BS, Mitsis D, Duggal N. Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine 2007; 7: 467-472



Croteau R. Wrong-Site Surgery – the Evidence Base. Presentation at NYSDOH Patient Safety Conference 2007



Freyer FJ. Hospital fined in wrong-site surgery. (Providence Journal online) Nov. 27, 2007



Mello F. Wrong-site surgery case leads to probe. 2d case of error at R.I. hospital this year (Boston Globe online) August 4, 2007









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