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Spine Surgery pp 585-597 | Cite as

Safety Checklist for Spine Patients

  • Sandro M. KriegEmail author
Chapter

Abstract

Errors are human. Nonetheless, we all pursue the aim not to produce errors at all and if they occur, not to harm the patient at least. Yet, with nowadays’ patient volume and critical time schedule, avoiding errors requires an ever-increasing level of attention. Operating a patient on the wrong level or wrong side is a nightmare mistake for surgeons, but however happens quite frequently. In a recent survey spine surgeons answered that 50% already performed wrong-level, and in 10% wrong-side surgery at least once.

References

  1. 1.
    Groff MW, Heller JE, Potts EA, Mummaneni PV, Shaffrey CI, Smith JS. A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to help avoid these errors. World Neurosurg. 2013;79(3–4):585–92.  https://doi.org/10.1016/j.wneu.2012.03.017.CrossRefPubMedGoogle Scholar
  2. 2.
    Mody MG, Nourbakhsh A, Stahl DL, Gibbs M, Alfawareh M, Garges KJ. The prevalence of wrong level surgery among spine surgeons. Spine (Phila Pa 1976). 2008;33(2):194–8.  https://doi.org/10.1097/BRS.0b013e31816043d1.CrossRefGoogle Scholar
  3. 3.
    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.  https://doi.org/10.1056/NEJMsa0810119.CrossRefPubMedGoogle Scholar
  4. 4.
    Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, et al. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010;22(5):365–70.  https://doi.org/10.1093/intqhc/mzq039.CrossRefPubMedGoogle Scholar
  5. 5.
    In: WHO guidelines for safe surgery 2009: safe surgery saves lives (WHO guidelines approved by the guidelines review committee). Geneva: World Health Organization.Google Scholar
  6. 6.
    Zuckerman SL, Green CS, Carr KR, Dewan MC, Morone PJ, Mocco J. Neurosurgical checklists: a review. Neurosurg Focus. 2012;33(5):E2.  https://doi.org/10.3171/2012.9.FOCUS12257.CrossRefPubMedGoogle Scholar
  7. 7.
    Saager L, Hesler BD, You J, Turan A, Mascha EJ, Sessler DI, et al. Intraoperative transitions of anesthesia care and postoperative adverse outcomes. Anesthesiology. 2014;121(4):695–706.  https://doi.org/10.1097/ALN.0000000000000401.CrossRefPubMedGoogle Scholar
  8. 8.
    Oszvald A, Vatter H, Byhahn C, Seifert V, Guresir E. “Team time-out” and surgical safety-experiences in 12,390 neurosurgical patients. Neurosurg Focus. 2012;33(5):E6.  https://doi.org/10.3171/2012.8.FOCUS12261.CrossRefPubMedGoogle Scholar
  9. 9.
    Wong JM, Bader AM, Laws ER, Popp AJ, Gawande AA. Patterns in neurosurgical adverse events and proposed strategies for reduction. Neurosurg Focus. 2012;33(5):E1.  https://doi.org/10.3171/2012.9.FOCUS12184.CrossRefPubMedGoogle Scholar
  10. 10.
    Berrisford RG, Wilson IH, Davidge M, Sanders D. Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit. Eur J Cardiothorac Surg. 2012;41:1326–9.CrossRefGoogle Scholar
  11. 11.
    Buzink SN, van Lier L, de Hingh IH, Jakimowicz JJ. Risksensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool. Surg Endosc. 2010;24:1990–5.CrossRefGoogle Scholar
  12. 12.
    Byrnes MC, Schuerer DJ, Schallom ME, Sona CS, Mazuski JE, Taylor BE, et al. Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Crit Care Med. 2009;37:2775–81.CrossRefGoogle Scholar
  13. 13.
    Calland JF, Turrentine FE, Guerlain S, Bovbjerg V, Poole GR, Lebeau K, et al. The surgical safety checklist: lessons learned during implementation. Am Surg. 2011;77:1131–7.PubMedGoogle Scholar
  14. 14.
    Chen M. A checklist for cerebral aneurysm embolization complications. J Neurointerv Surg. 2011. [epub ahead of print].Google Scholar
  15. 15.
    Chua C, Wisniewski T, Ramos A, Schlepp M, Fildes JJ, Kuhls DA. Multidisciplinary trauma intensive care unit checklist: impact on infection rates. J Trauma Nurs. 2010;17:163–6.CrossRefGoogle Scholar
  16. 16.
    Clark S, Belfort M, Saade G, Hankins G, Miller D, Frye D, et al. Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes. Am J Obstet Gynecol. 2007;197:480.e1–5.CrossRefGoogle Scholar
  17. 17.
    Connolly PJ, Kilpatrick M, Jaggi JL, Church E, Baltuch GH. Feasibility of an operational standardized checklist for movement disorder surgery. A pilot study. Stereotact Funct Neurosurg. 2009;87:94–100.CrossRefGoogle Scholar
  18. 18.
    Da Silva-Freitas R, Martín-Laez R, Madrazo-Leal CB, Villena-Martin M, Valduvieco-Juaristi I, Martínez-Agüeros JA, et al. Establishment of a modified surgical safety checklist for the neurosurgical patient: initial experience in 400 cases. Neurocirugia (Astur). 2012;23:60–9. (Span).CrossRefGoogle Scholar
  19. 19.
    de Vries EN, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg. 2010;4:6.CrossRefGoogle Scholar
  20. 20.
    de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg SM, Gouma DJ, Boermeester MA. Prevention of surgical malpractice claims by use of a surgical safety checklist. Ann Surg. 2011;253:624–8.CrossRefGoogle Scholar
  21. 21.
    de Vries EN, Hollmann MW, Smorenburg SM, Gouma DJ, Boermeester MA. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care. 2009;18:121–6.CrossRefGoogle Scholar
  22. 22.
    de Vries EN, Prins HA, Bennink MC, Neijenhuis P, van Stijn I, van Helden SH, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf. 2012;21:503–8.CrossRefGoogle Scholar
  23. 23.
    de Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363:1928–37.CrossRefGoogle Scholar
  24. 24.
    DuBose JJ, Inaba K, Shiflett A, Trankiem C, Teixeira PG, Salim A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. J Trauma. 2008;64:22–9.CrossRefGoogle Scholar
  25. 25.
    Fargen KM, Velat GJ, Lawson MF, Firment CS, Mocco J, Hoh BL. Enhanced staff communication and reduced near-miss errors with a neurointerventional procedural checklist. J Neurointerv Surg. 2012. [epub ahead of print].Google Scholar
  26. 26.
    Hart EM, Owen H. Errors and omissions in anesthesia: a pilot study using a pilot’s checklist. Anesth Analg. 2005;101:246–50.CrossRefGoogle Scholar
  27. 27.
    Kramer DR, Halpern CH, Connolly PJ, Jaggi JL, Baltuch GH. Error reduction with routine checklist use during deep brain stimulation surgery. Stereotact Funct Neurosurg. 2012;90:255–9.CrossRefGoogle Scholar
  28. 28.
    Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12–8.CrossRefGoogle Scholar
  29. 29.
    Lingard L, Whyte S, Espin S, Baker GR, Orser B, Doran D. Towards safer interprofessional communication: constructing a model of “utility” from preoperative team briefings. J Interprof Care. 2006;20:471–83.CrossRefGoogle Scholar
  30. 30.
    Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual. 2010;25:285–8.CrossRefGoogle Scholar
  31. 31.
    Matsumae M, Nakajima Y, Morikawa E, Nishiyama J, Atsumi H, Tominaga J, et al. Improving patient safety in the intra-operative MRI suite using an on-duty safety nurse, safety manual and checklist. Acta Neurochir Suppl. 2011;109:219–22.CrossRefGoogle Scholar
  32. 32.
    Nilsson L, Lindberget O, Gupta A, Vegfors M. Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes. Acta Anaesthesiol Scand. 2010;54:176–82.CrossRefGoogle Scholar
  33. 33.
    North American Spine Society. Sign, mark & x-ray (SMaX): prevent wrong-site surgery. (http://www.spine.org/Pages/PracticePolicy/ClinicalCare/SMAX/Default.aspx). [Accessed 25 Sept 2012].
  34. 34.
    Peyré SE, Peyré CG, Hagen JA, Sullivan ME. Reliability of a procedural checklist as a high-stakes measurement of advanced technical skill. Am J Surg. 2010;199:110–4.CrossRefGoogle Scholar
  35. 35.
    Peyre SE, Peyre CG, Hagen JA, Sullivan ME, Lipham JC, Demeester SR, et al. Laparoscopic Nissen fundoplication assessment: task analysis as a model for the development of a procedural checklist. Surg Endosc. 2009;23:1227–32.CrossRefGoogle Scholar
  36. 36.
    Robb WB, Falk GA, Larkin JO, Waldron R Jr, Waldron RP. A 10-step intraoperative surgical checklist (ISC) for laparoscopic cholecystectomy-can it really reduce conversion rates to open cholecystectomy? J Gastrointest Surg. 2012;16:1318–23.CrossRefGoogle Scholar
  37. 37.
    Romagnuolo J, Flemons WW, Perkins L, Lutz L, Jamieson PC, Hiscock CA, et al. Post-endoscopy checklist reduces length of stay for non-variceal upper gastrointestinal bleeding. Int J Qual Health Care. 2005;17:249–54.CrossRefGoogle Scholar
  38. 38.
    Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, et al. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff (Millwood). 2010;29:1593–9.CrossRefGoogle Scholar
  39. 39.
    Soyer HP, Argenziano G, Zalaudek I, Corona R, Sera F, Talamini R, et al. Three-point checklist of dermoscopy. A new screening method for early detection of melanoma. Dermatology. 2004;208:27–31.CrossRefGoogle Scholar
  40. 40.
    Taussky P, Lanzino G, Cloft H, Kallmes D. A checklist in the event of aneurysm perforation during coiling. AJNR Am J Neuroradiol. 2010;31:E59.CrossRefGoogle Scholar
  41. 41.
    Verdaasdonk EG, Stassen LP, Hoffmann WF, van der Elst M, Dankelman J. Can a structured checklist prevent problems with laparoscopic equipment? Surg Endosc. 2008;22:2238–43.CrossRefGoogle Scholar
  42. 42.
    Yu H, Neimat JS. The treatment of movement disorders by deep brain stimulation. Neurotherapeutics. 2008;5:26–36.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Neurosurgery, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany

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