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EGH Reportable Adverse Events (2010)

The following single (1) event was reported to the Indiana State Department of Health. To put this event in context, there were 12,827 patients discharged from Elkhart General Hospital in 2010. In the same year EGH also recorded 168,448 outpatient visits.

1. Surgical procedure performed on the wrong body part (July 2010)

A Kyphoplasty procedure at L3 (compression fracture) was scheduled for surgery however, the surgery was performed on L2. The level of the lesion was identified prior to the procedure through an exam, lab tests and imaging. On the day of the surgery, the surgeon reviewed the patient’s medical history and test results again to validate that the procedure was indicated. Before surgery, the patient’s lumbar MRI image was reviewed by the surgeon to determine the operating parameters which are used to guide the surgery. The patient’s MRI image was connected to the operating room monitor so the lesion was displayed in full view in real time. The patient was then positioned for surgery on the operating room table. For patient safety purposes and to ensure the accuracy of the location, two C-arm x-ray machines were used. A radio-opaque marker was also used to ensure the correct level (L3) of the operation was identified. The procedure occurred without incident and the patient experienced no adverse outcome. After surgery an image was obtained and shared with the patient after the procedure. A bone biopsy is always performed to ensure the correct diagnosis and to compare it to the pre-op diagnosis. At the patient’s follow up visit a L-spine X-ray was performed and it showed that a L2 Kyphoplasty was done. The patient reported no pain.

ACTION: A complete review of the case was conducted with the surgical team regarding the surgical process for Kyphoplasty. It was determined that all appropriate processes were followed according to policy. The physician made a full disclosure to the patient. It was determined that a second procedure was not needed because the patient reported an improvement in pain as a result of the initial surgery. Retrospectively, it was discovered that the patient already had a L2 fracture prior to the procedure. No further action was taken.

All Indiana Hospitals are required to report serious adverse events to the Indiana Department of Health. The State issues an annual report indicating the number of events at each hospital.