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From error to prevention of wrong-level spine surgery: a review

Patient Safety in Surgery volume 19, Article number: 16 (2025) Cite this article

Abstract

Wrong-level spine surgery remains a significant concern in spine surgery, leading to devastating consequences for patients and healthcare systems alike. This comprehensive review aims to analyze the existing literature on wrong-level spine surgery in spine procedures, identifying key factors that contribute to these errors and exploring advanced strategies and technologies designed to prevent them. A systematic literature search was conducted across multiple databases, including PubMed, Scopus, EMBASE, and CINAHL. The selection criteria focused on preclinical and clinical studies that specifically addressed wrong site and wrong level surgeries in the context of spine surgery. The findings reveal a range of contributing factors to wrong-level spine surgeries, including communication failures, inadequate preoperative planning, and insufficient surgical protocols. The review emphasizes the critical role of innovative technologies—such as artificial intelligence, advanced imaging techniques, and surgical navigation systems—alongside established safety protocols like digital checklists and simulation training in enhancing surgical accuracy and preventing errors. In conclusion, integrating advanced technologies and systematic safety protocols is instrumental in reducing the incidence of wrong-level spine surgeries. This review underscores the importance of continuous education and the adoption of innovative solutions to foster a culture of safety and improve surgical outcomes. By addressing the multifaceted challenges associated with these errors, the field can work towards minimizing their occurrence and enhancing patient care.

Introduction

Wrong-level spine surgery is a critical patient safety issue that has garnered significant attention in the surgical field, particularly in spine surgery [1, 2]. Wrong-level spine surgery can lead to devastating physical, psychological, and emotional repercussions for patients and their families [1, 3]. The consequences also extend to medical practitioners and healthcare institutions, often resulting in malpractice claims, loss of reputation, and the erosion of patient trust [4, 5].

Spine surgery, characterized by its complexity and the intricacies involved in anatomical navigation, poses unique challenges that heighten the risk of wrong-level spine surgery [5, 6]. An increasing number of surgical procedures, including spinal fusion, disc replacement, and decompression operations, necessitate precision and careful verification processes [7, 8]. Despite advancements in technology and safety protocols, incidents of wrong-level spine surgery persist, stressing the importance of ongoing vigilance and improvement in surgical practices [9,10,11,12,13].

Wrong-level spine surgery represents a critical patient safety concern within the surgical field, particularly in the complex domain of spine surgery [1, 2]. The consequences of wrong-level spine surgery are far-reaching, inflicting devastating physical, psychological, and emotional repercussions on patients and their families [1, 3]. Moreover, these errors extend their impact to medical practitioners and healthcare institutions, frequently leading to malpractice claims, reputational damage, and a loss of patient trust [4, 5].

The inherent complexity of spine surgery, with its intricate anatomical navigation, presents unique challenges that elevate the risk of wrong-level spine surgery [5, 6]. The increasing volume of surgical procedures, including spinal fusion, disc replacement, and decompression operations, all demand meticulous precision and rigorous verification processes [7, 8]. Despite technological advancements and the implementation of safety protocols, the occurrence of wrong-level spine surgery persists, underscoring the continuous need for heightened vigilance and ongoing improvements in surgical practices [9,10,11,12,13].

Although classified as “never events,” signifying their ideal absence, wrong-site spine surgeries, including wrong-level errors, unfortunately still occur [8, 11]. While the precise incidence remains challenging to ascertain due to underreporting and variations in data collection, large-scale studies generally report rates of less than 1% of all spine surgeries [14, 15]. Nevertheless, given the substantial number of spine surgeries performed annually, this seemingly small percentage translates to a significant number of potentially devastating errors. Alarmingly, some estimations suggest that over half of all spine surgeons may encounter at least one instance of wrong-level spine surgery during their professional careers [15, 16].

Certain surgical procedures inherently carry a greater risk profile for wrong-level surgery [15, 16]. Factors contributing to this elevated risk can be broadly categorized: patient-related factors such as anatomical variations (e.g., transitional vertebrae), obesity, a history of prior spine surgery, and spinal deformities like scoliosis [15, 17]; imaging-related issues including poor quality intraoperative X-rays or fluoroscopy, misinterpretation of imaging studies, and discrepancies between preoperative and intraoperative imaging, with an increased risk associated with relying solely on intraoperative imaging without careful correlation to preoperative scans [18, 19]; and technical issues encompassing inadequate preoperative planning, communication breakdowns within the surgical team, insufficient surgical protocols, surgeon fatigue or rushing, and the difficulty in visually distinguishing between adjacent spinal levels once the surgical site is exposed [20, 21]. Notably, the thoracic spine is recognized as a region with a higher propensity for wrong-level surgery compared to the cervical or lumbar spine [21, 22]. This increased risk is attributed to several factors: the scarcity of easily palpable bony landmarks [23,24,25], a higher incidence of anatomical variations such as rib anomalies and transitional vertebrae, challenges in obtaining clear intraoperative imaging due to shoulder obstruction, and subtle visual differences between vertebral levels [23,24,25]. Retrospective studies further indicate a higher occurrence of wrong-level surgeries in posterior thoracic procedures, likely due to the aforementioned challenges, particularly the difficulty in ascertaining the positional relationship between the spinous process and the vertebral body in this region due to the downward angulation of the spinous processes [23,24,25].

This review aims to explore the multifaceted issue of wrong-level spine surgery. It will highlight the various types of errors that can occur, analyze the underlying causes, and discuss the consequences faced by patients and healthcare providers. Furthermore, this article will detail existing preventative measures, evaluate current literature and research, and propose recommendations for future practice and policy. By addressing these critical aspects, we aspire to contribute to a safer surgical environment where such preventable errors become a rarity rather than a troubling reality.

Methods

Literature search strategy

We performed a systematic review to gather relevant literature on wrong-level spine surgery. Our search utilized several databases, including PubMed, Scopus, EMBASE, and CINAHL. To ensure comprehensive coverage, the search was not restricted by publication date but was limited to articles published in English. The search terms encompassed phrases such as “wrong-level spine surgery,” “wrong site spine surgery,” and “wrong procedure surgery.”

Inclusion and exclusion criteria

For this systematic review, we established specific criteria to determine the eligibility of articles for inclusion.

Inclusion criteria

To be considered for inclusion, articles had to be preclinical or clinical studies explicitly focusing on wrong-level spine surgery within the realm of spine surgery. Only studies published in English were eligible, and there were no restrictions on publication dates; both published and unpublished research could be included if they met the relevance criteria.

Exclusion criteria

Articles were excluded if they did not directly address wrong-level spine surgery. Additionally, case reports, commentaries, reviews, and editorials were also excluded to maintain a focus on original research. Non-English language publications were not considered, nor were studies that provided insufficient data or lacked detailed outcomes related to wrong site or wrong level surgeries.

By applying these criteria, we aimed to ensure that the included studies were relevant, rigorous, and contributed meaningfully to the understanding of the issue at hand.

Two independent reviewers assessed the eligibility of identified articles by examining their titles, keywords, and abstracts. In instances where disagreements arose, these were resolved through discussion and consensus. If necessary, a third reviewer was brought in to ensure an objective resolution. A PRISMA flow diagram visually summarizes our search methodology, screening process, eligibility assessment, and the final selection of studies included in the review.

Wrong-level spine surgery in spine surgery

Wrong level surgery refers to the performance of a surgical procedure at the incorrect spinal level, a critical aspect in spine surgery where precise location is essential for successful outcomes [15, 26]. This issue may stem from misinterpretation of imaging studies, such as MRIs or CT scans, which can lead to improper surgical planning. Insufficient reviews of a patient’s medical history, including previous surgeries and specific anatomical considerations, increase the likelihood of errors regarding the surgical level [16, 27]. Poor communication and dynamics within the surgical team can also result in misunderstandings about the planned procedure, contributing to wrong level surgeries. The impact of these errors is profound, potentially resulting in neurological deficits, increased pain, and extended recovery times, often necessitating further corrective surgeries [17, 28].

Wrong procedure surgery involves executing a surgical intervention that deviates from the originally agreed-upon plan. In this scenario, a surgical team carries out a procedure that does not align with the intent established during preoperative discussions [16, 17, 28, 29]. Such errors can occur due to inadequate documentation, where discrepancies between surgical consent forms and actual procedures may lead to confusion [18, 19]. Surgical team errors, including miscommunications and incomplete sharing of information regarding the intended operation, also contribute to this type of mistake [19, 30]. Additionally, the failure to comply with established safety protocols, including time-out procedures and checklists designed to reinforce the surgical plan, increases the risk of performing the wrong procedure [31, 32]. The implications of these errors can alter a patient’s life, leading to unnecessary complications, prolonged rehabilitation, and increased healthcare costs, while also inflicting long-term physical and emotional distress [20, 33] [Table 1].

Table 1 Summary of the key statements from the Article
Full size table

Causes and contributing factors to wrong-level spine surgery

Wrong-level spine surgery in spine surgery is often attributed to a combination of human and systemic factors, underscoring the complexity of ensuring patient safety in surgical environments. Understanding these causes and contributing factors is critical for implementing effective prevention strategies [20, 21, 34].

Human factors play a significant role in wrong-level spine surgery, with communication failures being a prominent contributor [22, 23]. In high-pressure surgical settings, clear and accurate communication among team members is essential for a successful surgical outcome [21]. Misunderstandings or lack of clarity regarding the surgical plan can lead to incorrect procedures being performed [24, 25]. Discrepancies in verbal communication, whether during preoperative briefings or in the operating room, can contribute to both wrong side and wrong level surgeries [35, 36]. Additionally, team dynamics—how team members interact and collaborate—can influence the effectiveness of communication. Poor collaboration and unclear roles within the surgical team can compromise information sharing, leading to increased risks of errors [37, 38].

Fatigue and distraction further exacerbate the likelihood of wrong-level spine surgery. The demanding nature of surgical work can lead to cognitive fatigue, which may impair decision-making abilities [38, 39]. Distractions in the operating room, whether from equipment malfunctions, interruptions during critical moments, or environmental noise, can divert attention away from the task at hand, increasing the risk of mistakes [39, 40]. These human factors—fatigue and distraction—underscore the importance of preserving focus and ensuring that surgical teams are alert and engaged during procedures [40, 41].

Systemic factors also contribute significantly to the occurrence of wrong-level spine surgeries. Inadequate preoperative protocols can create a gap in the verification process, which is crucial for confirming patient identity and the intended surgical site [42, 43]. When protocols are not strictly followed or are poorly designed, the risks of errors increase. For instance, the failure to mark the surgical site in compliance with established guidelines can lead to confusion during surgery [44, 45].

Errors in patient identification are another critical systemic factor. Misidentifying a patient can occur as a result of similar names, overlapping case schedules, or insufficient verification measures at various stages of the surgical process [46, 47]. When patients are not accurately identified, the risk of performing the procedure on the wrong person skyrockets [48, 49].

Documentation and informed consent issues are also pivotal contributing factors [49]. Inconsistent or unclear documentation can lead to misunderstandings about what procedures are approved, complicating the surgical team’s understanding of the planned intervention [50]. Similarly, when informed consent processes lack rigor, there can be discrepancies between what the patient understands they are undergoing and what the surgical team believes they are performing [51, 52].

Lastly, technological and instrumentation issues can introduce additional risks into the surgical process [51, 53]. The reliance on advanced surgical technologies and instruments, while enhancing precision in many cases, can also contribute to errors if the technology fails or is not appropriately utilized. For instance, incorrect calibration of navigation systems or misinterpretation of imaging results can lead to complications and wrong-level spine surgeries [43, 44].

Consequences of wrong-level spine surgery

Wrong-level spine surgery carries severe and far-reaching consequences that affect not only the patients involved but also healthcare providers and institutions [50, 51]. Understanding these repercussions is essential for emphasizing the need for preventative measures within surgical practices [10, 54].

Patient safety concerns are paramount in the discussion of wrong-level spine surgery. When a surgical procedure is performed on the wrong site, level, or patient, the immediate effect is often the compromise of the patient’s health and safety [4, 5]. Patients may experience unnecessary pain, complications, and a prolonged recovery period as they face the repercussions of an incorrect procedure. In some cases, wrong-level spine surgeries can lead to severe physical and neurological injuries, necessitating further surgeries to correct the mistake [26]. Such complications can result in long-lasting effects on patients’ quality of life, exacerbating their initial medical issues and creating additional burdens for them and their families [16, 26].

Beyond the immediate physical consequences, wrong-level spine surgery raises significant legal and ethical implications. Healthcare providers and institutions are exposed to legal liabilities when such errors occur, often leading to malpractice claims against surgeons and medical staff [17, 29]. These legal battles can be lengthy and costly, straining resources and diverting attention from patient care. Ethical questions also arise regarding the trust relationship between patients and healthcare providers. Patients place their trust in medical professionals to provide safe and appropriate care, and when that trust is violated, it can lead to a breakdown in the patient-provider relationship [18, 19]. The emotional distress experienced by patients and their families further highlights the ethical responsibilities held by healthcare providers to adhere to established protocols that ensure safety and minimize risk [25, 33].

The economic impact on healthcare systems cannot be understated. Wrong-level spine surgery leads to increased healthcare costs due to the need for corrective surgeries, extended hospital stays, and additional treatments resulting from complications [9, 29]. These costs strain healthcare resources, diverting funds from other critical areas of patient care. Institutions may also face fines, higher insurance premiums, and decreased revenue as a consequence of the legal actions that follow such incidents [12, 15]. As healthcare systems aim to improve efficiency and outcomes, the financial burden placed by wrong-level spine surgeries can hinder their ability to provide comprehensive care [14, 15].

Furthermore, the reputation of medical institutions is profoundly affected by incidents of wrong-level spine surgery [16, 18]. Institutions that experience such errors may suffer damage to their public image, leading to a loss of patient trust. Negative publicity can deter potential patients from seeking care, impacting the institution’s revenue and overall viability [30, 33]. A tarnished reputation can also affect the morale of healthcare employees, who may feel disheartened or demoralized in the wake of such incidents [20, 34]. To maintain a strong reputation, healthcare institutions must prioritize safety, adopt stringent verification protocols, and foster a culture of accountability and transparency [21, 22].

Prevention strategies for wrong-level spine surgery

Implementing effective prevention strategies is essential to mitigate the risk of WS in spine surgery [24, 25]. A multifaceted approach that combines robust protocols, technology, and education can significantly enhance patient safety and reduce the occurrence of such errors [24, 35].

Preoperative verification protocols are foundational to preventing wrong-level spine surgery. These protocols involve a series of steps designed to confirm the patient’s identity, the intended procedure, and the specific surgical site before the operation begins [35, 55]. A thorough verification process typically includes using the patient’s full name, date of birth, and surgical consent form to ensure accuracy. This process should involve not just the surgical team but also nursing staff and anesthesiologists, creating a comprehensive approach to patient verification that enhances safety [35, 36]. The importance of clearly marking the surgical site is also part of these protocols, as visual cues can serve as critical reminders during the procedure [36, 37].

Another vital component of prevention is the use of checklists and surgical time-outs. Checklists, modeled after those used in aviation, help ensure that all necessary preparations and safety checks are completed before surgery commences [38, 39]. During the surgical time-out, which is a brief pause taken just before the procedure begins, the surgical team reviews the patient’s information, the planned surgery, and the surgical site in a collective discussion [41]. This collaborative moment enables team members to voice any concerns or discrepancies, fostering open communication and reinforcing accountability. Research has shown that implementing these practices leads to a significant reduction in surgical errors, including wrong-level spine surgery [42, 43].

The role of imaging and navigation technology cannot be overlooked in the fight against wrong-level spine surgery. Advanced imaging techniques, such as MRI and CT scans, provide detailed anatomical views that help surgeons plan their approach with greater accuracy [44, 45]. Moreover, intraoperative navigation systems can assist surgeons in real-time, ensuring that they operate on the correct location in alignment with preoperative images. These technologies enhance the precision of surgical interventions, thus reducing the likelihood of errors related to anatomy and identification during procedures [24, 45].

Finally, education and training for surgical teams are critical components in preventing wrong-level spine surgery. Ongoing education about the risks associated with wrong-level spine surgeries and the importance of adherence to safety protocols will create a culture of safety and vigilance within the surgical setting [24, 35]. Regular training sessions can include simulations and role-playing scenarios that emphasize communication and teamwork, enabling team members to practice their response to potential errors in a controlled environment [33, 36]. By cultivating an atmosphere where continuous learning is prioritized, surgical teams can develop a heightened awareness of the factors contributing to wrong-level spine surgery and commit to the necessary practices that uphold patient safety [21, 22].

Future directions and recommendations for preventing wrong-level spine surgery

To effectively reduce the incidence of wrong-level spine surgery in spine surgery, it is crucial to identify future directions and make strategic recommendations [24, 25]. These approaches should focus on advancing research, implementing sound policies, and fostering a culture of safety within healthcare organizations [35, 36].

Areas needing further research are critical to understanding the multifaceted nature of wrong-level spine surgery. Continued studies could explore the effectiveness of various prevention strategies, such as the impact of checklist implementation and the role of team dynamics on surgical outcomes [37, 39]. Research should also investigate the psychological and organizational factors that contribute to human error in the surgical environment [41, 48]. By assessing the nuances of human behavior in clinical settings, stakeholders can develop more targeted interventions that address the root causes of wrong-level spine surgery [50, 53]. Additionally, there is a need for studies that evaluate the long-term effects of wrong-level spine surgeries on patient outcomes and the healthcare system, providing a comprehensive understanding of the implications of these errors [40, 53].

Policy recommendations for hospitals and surgical centers play a pivotal role in improving patient safety [40, 42]. Healthcare organizations should adopt standardized protocols that enforce rigorous preoperative verification processes, ensuring that they are consistently implemented across all surgical departments [25, 39]. Regular audits and assessments of compliance with these protocols are essential to identify gaps in adherence and facilitate continuous improvement. It is also advisable for surgical centers to create multidisciplinary committees focused on surgical safety, comprising surgeons, nurses, anesthetists, and quality assurance personnel [38, 41]. These committees can review incidents of wrong-level spine surgery, propose policy changes, and share best practices across the institution. Moreover, establishing clear accountability measures for surgical teams can help reinforce the importance of adhering to safety protocols [49, 52, 54].

Finally, fostering a culture of safety in healthcare organizations is paramount to mitigate the risk of wrong-level spine surgery. This culture emphasizes open communication, where team members feel safe to voice concerns without fear of retribution [42, 47]. Healthcare organizations must encourage reporting of near misses and other safety incidents, creating a learning environment where mistakes can be analyzed to prevent future occurrences [35, 39]. Implementing regular training sessions focused on teamwork, communication, and the importance of patient safety can contribute to this culture and empower staff at all levels to prioritize safe practices. Leadership commitment is also vital; administrators should actively promote safety as a core value and allocate resources to support training and safety initiatives [22, 23].

The role of AI and new technologies in reducing wrong level spine surgery

The integration of artificial intelligence (AI) and advanced technologies offers significant potential in addressing the critical issue of wrong level spine surgery, a concern that can severely impact patient safety and surgical outcomes [56]. These innovations enhance precision in surgical practices through several interconnected mechanisms [55].

AI-driven algorithms facilitate enhanced preoperative planning by analyzing extensive datasets, including previous surgical cases, medical imaging, and patient-specific characteristics. Through predictive analytics, AI identifies potential challenges and recommends optimal surgical approaches tailored to individual anatomical variations [57, 58]. Furthermore, advanced imaging techniques, such as 3D modeling and augmented reality, create precise visual representations of a patient’s spine, allowing surgeons to gain a deeper understanding of the intended surgical levels before entering the operating room [56, 57].

The evolution of imaging technologies, especially when integrated with AI, has led to significant improvements in accuracy and reliability [58, 59]. AI-powered image analysis can detect subtle anomalies or variations in spinal anatomy that may otherwise be overlooked, providing surgeons with clearer insights into the correct levels to address during surgery [60]. Additionally, intraoperative imaging technologies deliver real-time feedback, enabling immediate adjustments if any discrepancies arise during the procedure [45, 47].

Sophisticated surgical navigation systems, often enhanced with AI capabilities, serve as essential tools in minimizing the occurrence of wrong level spine surgeries [47, 60]. These systems utilize real-time data and advanced algorithms to guide surgeons with high precision throughout the surgical process [50, 52]. By overlaying digital images onto the surgical field, navigation systems help ensure that the correct anatomical landmarks are identified and adhered to, thus significantly reducing the potential for errors [41, 57].

Moreover, AI contributes to improving communication and error-checking protocols within surgical teams [58, 60, 61]. The integration of digital checklists into surgical workflows allows AI systems to prompt team members to verify critical information, such as the planned surgical site and corresponding imaging studies [60]. These reminders promote a heightened awareness of the surgical plan and reinforce adherence to established safety protocols, cultivating teamwork and a culture of safety in the operating room [61].

Another critical aspect is the role of AI and new technologies in surgical education through training and simulation [56, 61]. Virtual reality (VR) and augmented reality (AR) create immersive environments that allow surgical teams to practice complex spine procedures in a risk-free setting. These simulations enhance skill development and provide a thorough understanding of spinal anatomy, further decreasing the likelihood of surgical errors [56, 59].

Despite these clear advantages, integrating AI and new technologies does present certain challenges. Effective implementation necessitates comprehensive training for surgical staff to ensure proficiency with new systems and a solid understanding of their limitations [56, 59]. Furthermore, healthcare institutions must be vigilant to ensure that the adoption of technology does not detract from fundamental surgical principles or compromise the necessary hands-on oversight during procedures [56, 58, 61].

Limitations

This systematic review, while comprehensive in its examination of wrong-level spine surgery in spine surgery, has several limitations that should be acknowledged.

First, the review is inherently limited by the availability and quality of existing literature. The studies included in the review may vary in their methodological rigor, sample sizes, and definitions of wrong-level spine surgery, which could introduce variability in findings and limit the strength of conclusions drawn. Additionally, some studies may lack standardization in reporting outcomes related to wrong-level spine surgery, making it challenging to synthesize results effectively.

Second, the geographic and institutional diversity of the studies considered may impact the generalizability of the findings. The factors contributing to wrong-level spine surgery and the effectiveness of prevention strategies may differ significantly across regions, healthcare systems, and surgical practices. Thus, conclusions drawn from studies conducted in specific contexts may not be universally applicable.

Third, the review focuses predominantly on qualitative aspects of wrong-level spine surgery, such as human factors, communication, and team dynamics, while quantitative data and metrics regarding the prevalence of wrong-level spine surgery may be limited. A lack of comprehensive statistical analyses could restrict the ability to identify broader trends and correlations relevant to wrong-level spine surgery prevention.

Furthermore, this review may not account for all potential biases in the literature, including publication bias, where studies demonstrating negative outcomes are less likely to be published. This could skew the review’s insights and recommendations.

Lastly, the review primarily encompasses literature available up to October 2023. Since the field of surgical safety is continuously evolving, new technologies and practices may emerge that are not reflected in this review, leading to potentially outdated recommendations.

Conclusion

Wrong-level spine surgery is a significant patient safety issue with serious consequences. This article emphasizes the need for effective prevention strategies, including rigorous verification protocols, checklists, advanced imaging technology, and ongoing team education. To reduce wrong-level spine surgery occurrences, it is crucial to focus on research, policy implementation, and cultivating a culture of safety within healthcare organizations. By prioritizing these strategies, the healthcare community can enhance surgical safety and improve patient outcomes.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

We appreciate the Clinical Research Development Center of Imam Reza Hospital for their wise advice.

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There was no external source of funding.

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Authors and Affiliations

  1. Department of neurosurgery, Iran University of Medical Sciences, Tehran, Iran

    Parisa Javadnia

  2. Department of neurosurgery, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Hasti Gohari, Nila Salimi & Ehsan Alimohammadi

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  1. Parisa Javadnia
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  2. Hasti Gohari
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  3. Nila Salimi
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  4. Ehsan Alimohammadi
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Contributions

EA and PJ conceived and designed the study. HG and NS developed the search strategy and did the literature search. EA and PJ assessed the quality of study. HG and NS collected the data and performed all analysis. PJ, HG, and EA contributed to writing of original manuscript. All authors read and approved the final manuscript.

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Correspondence to Ehsan Alimohammadi.

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Javadnia, P., Gohari, H., Salimi, N. et al. From error to prevention of wrong-level spine surgery: a review. Patient Saf Surg 19, 16 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13037-025-00440-4

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13037-025-00440-4

Keywords

Patient Safety in Surgery

ISSN: 1754-9493