wlss guidelines

Overview: Patient Safety Framework for Mitigating Wrong-Level Spine Surgery

In an effort to proactively address emerging risks associated with changes in healthcare delivery, the Academic Medical Center Patient Safety Organization (AMC PSO) convened the Wrong-level Spine Surgery Safety Task Force to arrive at a set of consensus-supported guidelines for patient safety considerations for spinal surgery.

As technology advances and care evolves, opportunities exist to align and standardize practice to reflect this evolution.

The Task Force began with a review of the latest scientific evidence, guidance, and opinion statements from relevant professional societies, as well as input from frontline providers in Neurosurgical and Orthopedic Spine Surgery. Further insights were gathered from convening AMC PSO member subject matter experts across various surgical specialties, hospital operations, Anesthesiology, Nursing, Radiology, Risk Management, and Patient Safety.

What follows is a document that represents the aim, mission, and consensus opinion of the Task Force. It offers guidance for clinicians in their efforts to provide the safest possible care to patients.


  • Della Abedi-Tari
    Massachusetts General Hospital
  • Christopher Bono
    Brigham and Women’s Hospital
  • Lawrence Borges
    Massachusetts General Hospital
  • Kerry Carrara
    Beth Israel Deaconess Hospital-Milton
  • Brian Geller
    University of Florida Health Shands Hospital
  • Debra Clements
    Beth Israel Deaconess Hospital-Milton
  • Terence Doorly
    North Shore Medical Center
  • Pat Folcarelli
    Beth Israel Deaconess Medical Center
  • Daniel Hoh
    Univeristy of Florida Health Shands Hospital
  • James Holsapple
    Boston Medical Center
  • Carol Keohane
  • Louis Jenis
    Newton Wellesley Hospital
  • Russell Nauta
    Mount Auburn Hospital
  • Catherine O’Malley
    Massachusetts General Hospital
  • Efstathios Papavassiliou
    Beth Israel Deaconess Medical Center/Hospital-Milton
  • Ralph Reichle
    Mount Auburn Hospital
  • Debra Ricciardelli
    Massachusetts General Hospital
  • Daniel Rosenthal
    Massachusetts General Hospital
  • Laura Rossi
    Massachusetts General Hospital
  • Pierre Sasson
    Mount Auburn Hospital
  • Brooke Swearingen
    Massachusetts General Hospital
  • Chadi Tannoury
    Boston Medical Center
  • William Tomford
    Massachusetts General Hospital
  • Scott Tromanheuser
    New England Baptist Hospital
  • Andrew White
    Beth Israel Deaconess Medical Center
  • Ashley Yeats
    Academic Medical Center Patient Safety Organization
  • Katherine Zigmont
    Academic Medical Center Patient Safety Organization


The recommendations for Patient Safety Framework for Mitigating Wrong-level Spine Surgery were developed under the auspices of the Academic Medical Center Patient Safety Organization (AMC PSO) Spine Surgery Safety Task Force. These consensus recommendations are for informational purposes only and should not be construed or relied upon as a standard of care. The AMC PSO recommends institutions review these guidelines and accept, modify or reject these recommendations based on their own resources and patient populations. Additionally, institutions should continue to review and modify these recommendations as the field continues to evolve.

Download the Guidelines



More AMC PSO Content

Publications such as whitepapers and guidelines derived from the AMC PSO convenings.

    Patient Safety Guidance for Pathology Specimens

    The AMC PSO convened the Lost Specimens Task Force to offer guidance — and identify and mitigate risks — for specimen loss and mishandling that results in diagnostic error.

    EHR Downtime Guidelines

    At the request of its membership, the AMC PSO convened the task force to develop a set of literature-supported, consensus-based guidelines addressing patient safety considerations during unplanned EHR downtime events.

    Neonatal Encephalopathy Guidelines

    At the behest of its membership, the Academic Medical Center Patient Safety Organization convened a Task Force to arrive at a set of consensus-based guidelines for the most effective use of therapeutic hypothermia in cases of suspected neonatal encephalopathy.
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