Patient Safety Tip of the Week

September 14, 2010       Wrong-Site Craniotomy: Lessons Learned



There has really been a dearth of lessons learned on wrong-site neurosurgical procedures in the literature. Our November 25, 2008 Patient Safety Tip of the Week “Wrong-Site Neurosurgery” discussed some of those lessons that are available.


Now a new study (Cohen 2010) analyzes 35 cases of wrong-site craniotomy and provides insights into the factors which may contribute. The authors readily point out that the errors were recognized in most cases before the dura mater was violated so most affected patients did not end up with severe neurological deficits but the potential for disasters existed in all cases. They categorized root causes in 4 main areas:

  • Communication Breakdown
  • Technical Factors and Imaging
  • Inadequate Preoperative Checks
  • Human Error


Communication Breakdown


They mention working with unfamiliar staff as an example of communication breakdown. Keep in mind that doing a pre-op “huddle” is especially important when working with unfamiliar staff and part of either the universal protocol or the WHO surgical safety checklist includes adequate introduction of all staff in the OR.


Similar names were a factor in one case. And in others the communication breakdowns took place prior to the case reaching the OR.


But some of those cases were actually due to failure to buck the authority gradient, where someone in the OR recognized the laterality error but either failed to speak out or did speak out and was ignored.


Technical Factors and Imaging


Mislabeling of images or reports were contributory factors in several cases. In several others, changes in the conventions used for laterality were important. See our November 25, 2008 Patient Safety Tip of the Week “Wrong-Site Neurosurgery” for other comments about the potential for errors related to imaging in the OR.


One of the technical factors noted was absence of necessary equipment at the beginning of a procedure. As above, a pre-op “huddle” is especially important in identifying equipment that may be needed during a procedure and planning for contingencies. See our Patient Safety Tips of the Week December 9, 2008 “Huddles in Healthcare” and January 19, 2010 “Timeouts and Safe Surgery” for discussions on the pre-op huddle.



Inadequate Preoperative Checks


Failures in preoperative protocols contributed to almost half the cases and most of these were potentially preventable. These included things like failure to check the medical records or failure to mark the site. Failure to identify the laterality on the consent form was another contributory factor. (Note also that our What’s New in the Patient Safety World column for August 2010 “Surgical Case Listing Accuracy” mentioned the most common error in case listings booked for surgery was lack of laterality). But note that failure to use imaging studies properly in the preoperative assessment contribute frequently. This included absence of imaging studies, images belonging to the wrong patient, or scans hung backward.


Human Error


While one might argue that all the above also included some element of human error, the authors included several other contributing factors under the category “human error”. These included cases where faulty assumptions were made, especially when the patient was prepared for surgery by someone other than the surgeon him/herself. They also include time constraints, emergency cases, late night hours, and fatigue under this category.


They point out that critical steps in the verification process are often skipped because of the emergent nature of the cases. But the major adverse outcome in most of these cases is the delay in doing the surgery on the correct side.


Though the authors did not specifically comment on it, we suspect that most of the patients involved in these incidents did not have significant unilateral paralysis that should have alerted the neurosurgeons to the errors. Rather, most had non-focal neurological abnormalities or at least non-motor deficits. They also do not comment on whether the patient was capable of participating in the preoperative verification procedures or site markings (eg. were some patients aphasic, confused or demented?).


As per the Cohen article and the accompanying editorial (Cima 2010), one of the most striking facts is that only one of the 35 cases came from the peer-reviewed medical literature. Most of their cases were identified from media reports or malpractice databases. That is a clear indictment of a system (our current legal system and also our medical system) that suppresses the dissemination of lessons learned which could be used to prevent similar occurrences.


The authors discuss things that need to be done to prevent such wrong-site cases. They, of course, stress all the elements of universal protocol but especially focus on some of the factors they identified above. The importance of recording laterality on the consent (and booking) and review of all relevant pre-op medical record components by all staff cannot be overstressed. Verification of the patient using multiple identifiers and including the patient and/or family in the identification and marking processes is important. They have a good discussion of site marking for craniotomies. And they really focus on avoiding laterality issues with imaging studies. They discuss high tech solutions like software that accurately determines laterality and use of intraoperative computerized navigation devices. But they also discuss low tech solutions like placing a radio-opaque object on the side of the lesion so that the correct side will always be identified on any images done during the procedure.


Speaking of documentation of laterality, an article on wrong-site surgery in orthopedics (Masini 2010) addresses the issue of use of abbreviations in the consent form (or other parts of the medical record). Specifically, we often record in the medical record abbreviations like “RT” “LT” “R” “L” instead of spelling out “right” and “left”. It is much easier to misread or misinterpret the abbreviations.


We refer you back to our November 25, 2008 Patient Safety Tip of the Week “Wrong-Site Neurosurgery” for lots of other useful tips on how to avoid wrong-site cases in your organization.






Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention Clinical article 461. Journal of Neurosurgery 2010; 113: 461–473 (Posted online on 1 Sep 2010.)



Cima RR. Editorial Wrong-stie craniotomy 458.Response. Cohen FL, Mendelsohn D, Bernstein M . J Neurosurg 2010; 113: 458–460



Masini M. Recommendations offered to avoid wrong-site surgery in patients with multiple procedures. ORTHOPEDICS TODAY September 1, 2010
















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