This article by USC Spine Center Co-Director John C. Liu, MD, appeared in the July/August 2014 of Spine Surgery Today.
The National Transportation Safety Board recently announced that the crash of Asiana Airline flight 214 resulted from the crew being too reliant on the technology. In addition, the copilots were reluctant to question moreseasoned pilots.
Spine surgeons can take a valuable lesson from this example of pilot mismanagement into their medical practices. We have all seen someone or heard horror stories about surgeons who do not let anyone – colleagues, residents, students, nurses – question them. Only when we are willing to listen to others and slow down to review cases with our team will mistakes, like those made in the issue’s Cover Story, not happen.
While thoughts of the number of callbacks needed, consultations waiting and surgeries yet to be done naturally go through our minds throughout the day, it is important to collect one’s thoughts and let other problems fade. Staying focused during a case can prevent incidents, like wrong-level surgery, from happening. Also when something unexpected does occur, you are ready. Your mind is able to think of many possible fixes and you can implement back-up plans when unexpected events change the normal course of surgery. This will only occur when a surgeon remains calm and collected for the surgery, which all starts with a surgical “time-out.”
Follow the guidelines
The new Joint Commission Guidelines for Implementation of the Universal Protocol for the Prevention of Wrong Site, Wrong Procedure and Wrong Person Surgery is what spine surgeons needed. The guidelines provide for a surgical time-out before procedures so everyone in the operating room (OR) is on the same page. Ironically, the guidelines stemmed from the preflight time-outs used in the aviation industry before every flight’s takeoff. So even though time-outs may take a few extra minutes nor do they always prevent wrong-level surgery, they do improve patient care.
Mentally preparation for a case is important. In years past, I was taught by my mentor to use the 10-minute scrub time before a surgery to let everything fall away from a chaotic schedule and just focus on the patient at hand. Now it only takes a moment with surgical gel, which is not enough time to slow down and concentrate. Wrong-level surgery, which is most likely widely under-reported, is not worth the risk to a career or patients. You should collect your thoughts with a surgical time-out.
Time to focus, double check
Simple techniques are important. Ask yourself if you have the correct films for the correct patient. Checking simple things can be done without much fanfare, but double checking makes a big difference to patients.
Make sure to count the levels of the spine the same way intraoperatively as you would read a MRI. Think about the patient’s anatomy and the quality of the films. Don’t settle for suboptimal intraoperative imaging.
Think about the OR staff. Have they all agreed that this is the correct patient and the correct procedure? Do you know everyone who is working in the OR with you? There may be a neuromonitoring technician who always works in the OR who you have never heard speak. This is the chance to find out his or her name and give them a chance to talk. At some point in the future, this person could be the one person who speaks up and points out that you were about to perform an L4-5 instead of an L5- S1 discectomy. Everyone in the OR needs to take a moment to agree on the procedure to be performed – from the correct level to the correct patient and who is doing what.
Time-outs allow spine surgeons to focus on the surgery at hand and let the rest of the day fall away. We need to be ready for what the next few hours could bring. If your hospital has yet to use the new Joint Commission guidelines and checklists, then encourage their use. It can make a difference to your career and your patients.