Wrong-site craniotomy.

In this is issue of the Journal of Neurosurgery, Cohen and colleagues 1 report on a systematic review of the medical and legal literature as well as media reports relating to wrong-side craniotomies. Included with their description of 35 reported cases, they have provided analysis of possible contributing factors. Not surprisingly, the most common contributing factor was a breakdown in communication. What is most striking and disconcerting is the observation that only one of the cases was reported in the peer-reviewed medical literature. A failure to recognize and discuss such events within the neurosurgical and broader medical community does nothing to prevent them. Instead, silence may actually permit these events to recur because valuable lessons learned by the hospitals and physicians involved are not shared with colleagues. This concern is not limited to neurosurgeons. Devastating events in other specialties are rarely discussed openly within our medical communities. Unfortunately, they are often broadcast widely in the public media with a laser-beam focus on the physician or the incident and issues of malpractice. This commotion and defensive posturing consume energy that would be better directed at improving processes to avoid such events. As reflected by publication of this article, the impact of medical errors on both an individual and societal level has received increased attention over the past decade. In 2000, the Institute of Medicine report " To Err Is Human: Building a Safer Health System " estimated that preventable medical errors could be responsible for up to 98,000 deaths per year in the US. 5 After the IOM report, the National Quality Forum published a list of 27 preventable adverse events that should never occur in the US health care system. 8 These events were labeled as " never events. " Three of the 27 never events were surgery on the wrong site/side, wrong procedure, or wrong patient. The inclusion of these dramatic and possibly catastrophic events resulted from an alert released by the Joint Commission, formerly known as the Joint Commission on Accredita-tion of Healthcare Organizations, in August 1998, examining wrong site/side surgeries. 2 The alert included a review of 15 cases that had been voluntarily reported to the JC Sentinel Event system, which was established in 1995. This database was loosely fashioned on the federal aviation event reporting system in which errors or incidents that could or did influence flight safety are anonymously reported. The most recent review of …