From error to prevention of wrong-level spine surgery: a review

Abstract Wrong-level spine surgery remains a significant concern in spine surgery, leading to devastating consequences for patients and healthcare systems alike. This comprehensive review aims to analyze the existing literature on wrong-level spine surgery in spine procedures, identifying key factor...

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Main Authors: Parisa Javadnia, Hasti Gohari, Nila Salimi, Ehsan Alimohammadi
Format: Article
Language:English
Published: BMC 2025-05-01
Series:Patient Safety in Surgery
Subjects:
Online Access:https://doi.org/10.1186/s13037-025-00440-4
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author Parisa Javadnia
Hasti Gohari
Nila Salimi
Ehsan Alimohammadi
author_facet Parisa Javadnia
Hasti Gohari
Nila Salimi
Ehsan Alimohammadi
author_sort Parisa Javadnia
collection DOAJ
description Abstract Wrong-level spine surgery remains a significant concern in spine surgery, leading to devastating consequences for patients and healthcare systems alike. This comprehensive review aims to analyze the existing literature on wrong-level spine surgery in spine procedures, identifying key factors that contribute to these errors and exploring advanced strategies and technologies designed to prevent them. A systematic literature search was conducted across multiple databases, including PubMed, Scopus, EMBASE, and CINAHL. The selection criteria focused on preclinical and clinical studies that specifically addressed wrong site and wrong level surgeries in the context of spine surgery. The findings reveal a range of contributing factors to wrong-level spine surgeries, including communication failures, inadequate preoperative planning, and insufficient surgical protocols. The review emphasizes the critical role of innovative technologies—such as artificial intelligence, advanced imaging techniques, and surgical navigation systems—alongside established safety protocols like digital checklists and simulation training in enhancing surgical accuracy and preventing errors. In conclusion, integrating advanced technologies and systematic safety protocols is instrumental in reducing the incidence of wrong-level spine surgeries. This review underscores the importance of continuous education and the adoption of innovative solutions to foster a culture of safety and improve surgical outcomes. By addressing the multifaceted challenges associated with these errors, the field can work towards minimizing their occurrence and enhancing patient care.
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spelling doaj-art-59909acb6feb428fa341e2feb795536a2025-08-20T03:07:54ZengBMCPatient Safety in Surgery1754-94932025-05-011911810.1186/s13037-025-00440-4From error to prevention of wrong-level spine surgery: a reviewParisa Javadnia0Hasti Gohari1Nila Salimi2Ehsan Alimohammadi3Department of neurosurgery, Iran University of Medical SciencesDepartment of neurosurgery, Kermanshah University of Medical SciencesDepartment of neurosurgery, Kermanshah University of Medical SciencesDepartment of neurosurgery, Kermanshah University of Medical SciencesAbstract Wrong-level spine surgery remains a significant concern in spine surgery, leading to devastating consequences for patients and healthcare systems alike. This comprehensive review aims to analyze the existing literature on wrong-level spine surgery in spine procedures, identifying key factors that contribute to these errors and exploring advanced strategies and technologies designed to prevent them. A systematic literature search was conducted across multiple databases, including PubMed, Scopus, EMBASE, and CINAHL. The selection criteria focused on preclinical and clinical studies that specifically addressed wrong site and wrong level surgeries in the context of spine surgery. The findings reveal a range of contributing factors to wrong-level spine surgeries, including communication failures, inadequate preoperative planning, and insufficient surgical protocols. The review emphasizes the critical role of innovative technologies—such as artificial intelligence, advanced imaging techniques, and surgical navigation systems—alongside established safety protocols like digital checklists and simulation training in enhancing surgical accuracy and preventing errors. In conclusion, integrating advanced technologies and systematic safety protocols is instrumental in reducing the incidence of wrong-level spine surgeries. This review underscores the importance of continuous education and the adoption of innovative solutions to foster a culture of safety and improve surgical outcomes. By addressing the multifaceted challenges associated with these errors, the field can work towards minimizing their occurrence and enhancing patient care.https://doi.org/10.1186/s13037-025-00440-4Wrong-level spine surgerySpine surgerySafety protocolsSurgical accuracy
spellingShingle Parisa Javadnia
Hasti Gohari
Nila Salimi
Ehsan Alimohammadi
From error to prevention of wrong-level spine surgery: a review
Patient Safety in Surgery
Wrong-level spine surgery
Spine surgery
Safety protocols
Surgical accuracy
title From error to prevention of wrong-level spine surgery: a review
title_full From error to prevention of wrong-level spine surgery: a review
title_fullStr From error to prevention of wrong-level spine surgery: a review
title_full_unstemmed From error to prevention of wrong-level spine surgery: a review
title_short From error to prevention of wrong-level spine surgery: a review
title_sort from error to prevention of wrong level spine surgery a review
topic Wrong-level spine surgery
Spine surgery
Safety protocols
Surgical accuracy
url https://doi.org/10.1186/s13037-025-00440-4
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