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Cases & Commentaries
- Spotlight Case
- Web M&M
Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH; May 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Journal Article > Study
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Although instances of wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) have been widely publicized, the true incidence of such errors remains unclear. A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in the outpatient setting or in ambulatory surgery as well. In this study, the authors reviewed four databases to determine the incidence of all WSPEs, including procedures performed outside the operating room. Data from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur yearly, with many occurring during outpatient procedures. The authors argue that all WSPEs should be considered preventable, and recommend reporting and prevention standards for reducing such errors.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
O'Reilly KB. American Medical News; Nov. 1, 2010.
This article reports on recent study findings indicating that the Universal Protocol has not stopped wrong-patient, wrong-site procedures.