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Sign, Mark & X-ray (SMaX): Prevent Wrong-Site Surgery


In 1998, the Institute of Medicine (IOM) formed the Quality of Healthcare in America Committee to plan improvements in health care quality over the next 10 years. One facet of that improvement effort is the reduction of medical errors and increased attention to patient safety.

The IOM's first report on patient safety, To Err Is Human (2000), cited large numbers of medical errors that allegedly occur each year in the US health system. According to the report, medicine is behind other high risk industries in acknowledging and addressing safety issues. The report also identified health care providers as an integral part in improving patient safety.

There are 2 ways health care providers can become involved in improving safety for their patients: participating in or helping their institution develop nonpunitive, confidential reporting practices; and using prevention tools in their individual practices and institutions.

Although experts disagree on the number of medical errors that occur each year, everyone agrees that patient safety is an important issue that deserves attention. The North American Spine Society (NASS) is committed to quality patient care through the promotion of patient safety and the prevention of medical errors. NASS believes nonpunitive, confidential reporting is an important preventive measure. Found in other industries with established safety systems (most notably aviation), the goal of nonpunitive, confidential reporting is to identify errors, including near misses, for the purpose of correction and prevention-not punishment or liability.

In order to help practitioners protect their patients, NASS has developed prevention tools to enhance patient safety and encourages their use by members.

Wrong-Site Spine Surgery

While the incidence of wrong-site surgery is not high, the consequences to the patient and surgeon can be severe. Wrong-site surgery (operating on the wrong anatomical site) is easily prevented. Risk factors for wrong-site surgery include involvement of multiple surgeons; multiple procedures performed during a single trip to the operating room; time pressures; and unusual patient characteristics. Two types of communication issues also have been identified related to wrong-site surgery: failure to involve the patient in identifying the site and incomplete or inaccurate communication between surgical team members. The most common error in spine surgery occurs when a procedure is done one level above the intended site.

In order to help prevent wrong-site spinal surgery, the Sign, Mark & X-ray (SMaX) campaign has been developed. NASS encourages members to share the campaign protocols and tools with their colleagues and operating room staff. Please feel free to download and make copies of these documents to use in your practice.

  • Sign, Mark & X-ray Checklist for Safety. This checklist outlines a series of steps and double-checks to avoid wrong-site spine surgery.
  • Take-Home Sheet: Patient Diagnosis Diagram. This take-home sheet provides a diagram for the physician to outline the site(s) of pathology to the patient during office discussions. There is space to specify the differential diagnosis and plan of treatment (including the side and levels of any proposed surgery). The patient can share this summary of the office visit with other health care providers such as physical therapists. When brought to surgery, the handout serves as an additional check of side and level to avoid wrong-site surgery.
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