1200 Reducing Wrong-Site Spine Surgeries: An Update of a Single Tertiary Institution’s Iterative Policy

INTRODUCTION: Wrong-site spine surgery (WSSS) is a rare adverse event associated with spinal surgery and is any spinal procedure conducted on an unintended anatomic location. Our institution experienced fifteen WSSS incidents between 2008 and 2019 at a run rate of 0.708 WSSS per 1,000 surgeries. In 2018, our institution introduced a policy update to decrease WSSS. This policy update introduced a secondary verification step by a remote radiologist assessing intraoperative X-rays of the localization. Then, the radiologist engages in a secure chat with the surgeon in the operating room to confirm the localization. METHODS: All WSSS and prevention strategies utilized at our institution between the implementation of the policy and 2023 were reviewed. A chi-square test was utilized to analyze the significance of the policy update in reducing WSSS. RESULTS: After the implementation of the policy from 2019 to 2023, one WSSS occurred at our institution with a WSSS run rate of 0.056 WSSS per 1,000 surgeries. The cause of the one WSSS was deemed to be a systems error that occurred due to an assessment and information management problem. The policy update at the end 2018 was effective and significantly reduced the rate of WSSS occurring at this institution (P = 0.0009). CONCLUSIONS: Having a radiologist verify the intraoperative localization in real time is effective in decreasing the rate of WSSS. Other institutions may want to consider implementing a similar protocol to reduce their rate of WSSS.