How Many Surgeons Does It Take To Count Your Vertebrae?

counting_blocks.gifOver the past four months, orthopedic surgeons at Beth Israel Deaconess Medical Center have committed the same surgical error three different times – by operating on the wrong vertebra of patients undergoing back surgery.
According to recent news stories about the errors, two of the “wrong site” surgical errors were uncovered only after patients complaining of ongoing back pain underwent post-operative x-rays. One surgeon committed the same “wrong level” error twice between September and December of 2010.
After the third error occurred, the Boston hospital implemented new procedures to avoid further repetition of the error. The new procedures include following a checklist developed by New England Baptist Hospital to help surgeons mark the correct vertebrae during surgery. We’ve blogged about the importance of such checklists and American hospitals’ reluctance to adopt them here, here and here.
Thankfully, none of the patients seem to have suffered any permanent harm as a result of the medical mistakes and at least one patient’s back pain seems to have spontaneously resolved even after the wrong vertebra was operated on.
Dr. Kenneth Sands, senior vice president of health care quality for Beth Israel Deaconess, said that the spate of back surgery errors, “…is really strange and we really don’t have an answer as to why these happened” in a cluster.
In at least one of the cases, however, it appears that the presiding surgeon and a surgical fellow who was assisting him followed different systems for numbering the vertebrae and, consequently, a miscommunication occurred about what vertebra was to be operated on.
The answer to the age-old question, “How many surgeons does it take to count your vertebrae?” appears to be, “More than two, at least if they’re using different numbering systems.”
Let’s hope the new checklists at Beth Israel Deaconess get their surgeons on the same page.

This blog is maintained by the Boston medical malpractice lawyers at The Law Office of Alan H. Crede. The blog does not contain or offer legal advice.