Wrong-site craniotomy: analysis of 35 cases and systems for prevention

Object. The purpose of this case review was to identify and analyze existing wrong-site craniotomy (WSC) cases to determine the factors that contributed to the errors and to suggest preventative strategies for WSC. Wrong-site surgery (WSS) is a devastating surgical error that has gained increased public attention in recent years due to some high-profile cases. Despite the implementation of preventative methods such as preoperative checklists and surgical time-outs, WSS still occurs to this day. The clinical consequences of WSC are distinct compared with other types of WSS due to the unique function of the brain. Methods. The authors searched medical, legal, and media databases and contacted state medical licensing boards to identify and gather information about WSC cases. The cases were reviewed and analyzed for factors that contributed to the errors. Results. Four major categories of contributing factors were found: 1) communication breakdown; 2) inadequate preoperative checks; 3) technical factors and imaging; and 4) human error. The WSC cases are used to illustrate how these types of factors can precipitate the surgical error. Clinical outcomes and disciplinary actions are summarized. Obtaining information about the cases discovered was very challenging, in part because WSS reporting is inadequate. Conclusions. This case review demonstrates that a broad range of events and factors can cause human errors to breach patient safeguards and lead to a WSC; however, in essentially all cases the WSCs were preventable with strict adherence to comprehensive and thorough protocols. (DOI: 10.3171/2009.10.JNS091282)