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Radiology Daily
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Despite Precautions, Wrong-Site Surgeries Still Occur

March 2, 2008
Written by: , Filed in: Practice Management
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Despite everyone’s best efforts to avoid the ‘never event’ of wrong-site
surgery, this preventable error continues to occur. For example, one wrong-
site surgery occurs in Pennsylvania every five days.

‘Never events,’ as defined by the National Quality Forum (NQF), include a list
of 28 preventable medical errors that result in adverse patient outcomes.
Other terminologies may overlap with ‘never events.’

The term ‘never events’ may be intermingled with ‘sentinel events,’
particularly in the State of Pennsylvania, where we are currently practicing.
Also the term ‘serious events’ often overlaps with ‘never events.’

Therefore, something that could be labeled as a ‘never event’ for billing
purposes, for Centers for Medicare and Medicaid Services (CMS) purposes, or
for insurance purposes, may be considered a sentinel event as defined by the
Joint Commission on Accreditation of Healthcare Organizations and by the
Pennsylvania Patient Safety Authority. These serious recordable events can be
classified into six different categories. The first of these categories
involves surgical or procedural complications, which contains several items.

Wrong-Site Surgery:
The first item is surgery performed on the wrong body part. There has been an
enormous amount written on how to prevent this error. Every existing hospital
has a procedure or policy on how to prevent wrong-site surgery. However, in
the 2009 National Patient Safety Goals, the Joint Commission indicated that
this was a continuing problem across the United States, and introduced the
idea of the “Universal Protocol.”

The Universal Protocol means that in the operating room, health care personnel
must stop or take a time-out before the procedure begins to verify that they
have the right patient, the right devices, the right implantables, and know
the correct body part on which surgery will be performed.

Despite everyone’s best efforts, wrong-site surgery continues to occur. For
example, based on reports to the Pennsylvania Patient Safety Authority, there
is one wrong-site surgery in Pennsylvania every five days despite the adoption
of the Universal Protocol.

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events:
Wrong-Site Surgery and the Universal Protocol

Despite everyone's best efforts to avoid the 'never event' of wrong-site surgery, this preventable error continues to occur. For example, one wrong- site surgery occurs in Pennsylvania every five days. 'Never events,' as defined by the National Quality Forum (NQF), include a list of 28 preventable medical errors that result in adverse patient outcomes. Other terminologies may overlap with 'never events.' The term 'never events' may be intermingled with 'sentinel events,' particularly in the State of Pennsylvania, where we are currently practicing. Also the term 'serious events' often overlaps with 'never events.' Therefore, something that could be labeled as a 'never event' for billing purposes, for Centers for Medicare and Medicaid Services (CMS) purposes, or for insurance purposes, may be considered a sentinel event as defined by the Joint Commission on Accreditation of Healthcare Organizations and by the Pennsylvania Patient Safety Authority. These serious recordable events can be classified into six different categories. The first of these categories involves surgical or procedural complications, which contains several items. Wrong-Site Surgery: The first item is surgery performed on the wrong body part. There has been an enormous amount written on how to prevent this error. Every existing hospital has a procedure or policy on how to prevent wrong-site surgery. However, in the 2009 National Patient Safety Goals, the Joint Commission indicated that this was a continuing problem across the United States, and introduced the idea of the "Universal Protocol." The Universal Protocol means that in the operating room, health care personnel must stop or take a time-out before the procedure begins to verify that they have the right patient, the right devices, the right implantables, and know the correct body part on which surgery will be performed. Despite everyone's best efforts, wrong-site surgery continues to occur. For example, based on reports to the Pennsylvania Patient Safety Authority, there is one wrong-site surgery in Pennsylvania every five days despite the adoption of the Universal Protocol. Reference: Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events: Wrong-Site Surgery and the Universal Protocol [text_ad]
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