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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, 0pportunities 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.
TASK FORCE
- 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
CRICO
- Louis Jenis
Newton Wellesley Hospital
- Russell Nauta
Mount Auburn Hospital
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- 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
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STATEMENT
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..