One of the questions I often received prior to the first annual spine safety summit in 2016 is “why organize another Spine Surgery conference?” My answer is inevitably, “how could we not?”

The time could not be more urgent. At every talk I give, I always like to put the audience in the right mindset, which is “how will the next patient be harmed?” Somewhere out there, there’s a patient coming to your waiting room or in a cab or on a plane that may be harmed. The question isn’t if, but when.

In reality, no one is safe, the patient or the surgeon, including the emotional toll that comes from potentially harming a patient.

As a field, we are not doing well. Even if we pride ourselves with 99.9% positive outcomes, we are still left in the dust by others who are doing better. As a framing picture, we would find this unacceptable if:

• Amazon failed to deliver 1,600 parcels each day
• USPS lost 506,000 pieces of mail each day
• 1,019 surgeries went wrong every month

We always need to ask ourselves, how far would you be willing to go to avoid harm? Often times, the answer isn’t from punishing physicians and nurses. It’s not an issue of bad physicians or nurses harming patients, but a poor system setting up good physicians and nurses that eventually harms patients. Even the most technically skilled and fantastic of surgeons can’t do a great job, unless they have the infrastructure to support them and a team surrounding them with good communication. More and more, with lessons from high reliability organizations such as aviation and nuclear power as well as from the peer-reviewed literature, we are learning that over focusing on the concepts of individual skills undervalues the reality that care is a result of the entire episode of care, requiring a systematic approach to managing everything within the realm of influence, from preoperative access to recovery and rehabilitation.

Just like Jim Reason’s timeless model, the Swiss Cheese Model of Medical Error, if we think about all of the elements of risk, host, technique, systems, and culture, then we realize that medical error and complications occur only when all of the holes line up just right.

As we start this blog, I am hopeful that the Safety in Spine Surgery Project (S3P) will evolve into a platform where we can engage the wisdom of the entire industry to shrink the critical holes that too often lead to poor outcomes for our patients:

• Variability
• Lack of Infrastructure
• Individual Thinking & Decision Making
• Lack of Information in a Data Rich System
• Poor Culture

S3P will provide an infrastructure and platform in which we can work together to tackle some of these issues throughout spine surgery and hopefully implement strategies across the board. But we need participation and buy in at ever level, from industry partners, hospitals, peers and colleagues, and each individual physician. Patient safety and quality starts with physicians, but it doesn’t end there.

This is such an exciting time and we would love your feedback on how S3P can take quality in spine surgery to the next level. In future blog posts, we’ll talk more about some of the frameworks for change we envision and the efforts that have evolved as a result. We look forward to hearing from you.

Developing the Wrong Site Surgery Checklist

Far too often, healthcare fails to provide the level of reliability that is expected around a patient’s sense of quality. Even meeting quality and safe patient care 99.9% of the time may not be enough. For reference, if 99.9% was an appropriate threshold, Amazon would still be failing to deliver 1,600 packages per day and the US Postal Service would be losing 506,000 parcels per day.

Yet, healthcare can learn to apply many of the principles in high reliability to improve patient care. One of the lessons we consistently present as part of S3P’s efforts is the story of the Boeing Corporation Model 299.

At the time in World War II, it was a newly developed “flying fortress” that could carry five times the bombs of Martin and Douglas planes, and could fly both faster and twice as far. By all accounts, the US government believed that this was the plane that would help them end World War II.

Unfortunately, the plane proved to be unreliable and dangerous, killing the test pilot in the first attempt to fly it. According to other of the air force’s top test pilots, the controls were so complex with its fly by wire systems that it was considered “too much plane for one man to fly.” This complexity was leading to what Shojana refers to as “mistakes by good but fallible people in dysfunctional systems”

As a result, the Boeing 299 development team worked with the test pilots to create a checklist of all the steps required for takeoff, flight, landing and taxiing, using principles of human factors engineering and ergonomics to ensure it was as easy to use as possible. After implementation, 1.8 million test miles were logged without incident. Ultimately, the Army bought 13,000 aircraft, which became a key part of the bombing campaign that led to Nazi defeat in WWII.

The use of checklists, when properly considering stakeholder and surgeon input and appropriately implemented, can help us eliminate errors, improve team communications and reduce complications. S3P has used these with experts in the field to create several evidence and consensus-based checklists including:

• Pre, intra, and postoperative processes to prevent Surgical site infection
• Responding to intraoperative neuromonitoring changes during spine surgery
• Preventing wrong level spine surgery

While the original Boeing checklist was used on paper, as are many OR checklists, S3P is looking to adapt to the 21st century and catch up to Aviation’s digital checklists built into the controls of many airplanes. These checklists are tied directly to sensors within the aircraft and can respond with intelligent logic when items are needed and not needed. Today, these are being tested within the OR to help reduce burden on the team, while feeding back real-time, critical information for feedback and quick prototyping.

We look forward to sharing the results of these experiments to make care better with you as we all progressing to improving quality, safety, and value in Spine Surgery.