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from improving patient care processes to explaining
the circumstances surrounding a single event. As Dr.
Paull said, “Zero harm does not mean zero error! Key
to patient safety is preventing errors from reaching
patients and causing harm. Never events represent the
low threshold for participation in health care. That is
why there is mandatory reporting of such events in
many states. Close calls and such are what HROs focus
upon. No patient actually gets hurt [in these instances]
but we do not want anything to happen in future”
(personal communication via e-mail, July 31, 2016).
Seeing the concepts in action
Following a 2015 report regarding the persistence
of wrong site spine surgery and pain intervention
events, a regional spine surgeon and pain intervention specialist workgroup was established to attempt
to understand the root cause(s) of this problem. The
natural assumption presented to our group was that
when wrong level procedures occurred, there must
have been willful violation of known precautions. The
specialists reiterated that, in their experience, this did
not seem to be the case. Their opinion was that, in
most cases, the universal protocol was likely followed
throughout the procedure and that other factors were
at play. The participants recommended that physicians
take the lead in education regarding the effects of the
following factors on error: 24
•Distraction and fatigue
•Routineness of procedure, complacency
•Communication problems, including handoffs
•Equipment or staff problems during localization
•Patient characteristics: Body habitus, spinal deformities, vertebral morphological variant
•Confirmation bias: Accepting inadequate views due
to positioning in lieu of alternate/additional imaging
or secondary confirmation with an additional expert
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