Never Events: Wrong Site Surgery
Current Patient Safety Initiatives Impacting Foot and Ankle
- Calling all administrative/clinical leaders and policymakers interested
in patient safety. Opportunities to reduce healthcare-associated infections
through collaboration among health systems, hospitals, and government
organizations. The U.S. Department of Health and Human Services and hospital
leaders of the Texas Medical Institute of Technology's (TMIT) collaborate on the
“Greenlight Program.” For more information visit SafetyLeaders.
- CMS and
JCAHO address so-called never events, which are serious preventable errors in
surgical care. ACFAS strongly supports these efforts. CMS has addressed the
issue through Medicare payment policy and issued three national coverage
determinations (NCDs), making clear that Medicare will not pay providers or
facilities for care rendered during a never event. The three NCDs are:
- Wrong surgical or other invasive procedure performed on a patient.
- Surgical or other invasive procedure performed on the wrong body part.
- Surgical or other invasive procedure performed on the wrong
For all three events, CMS provides that a surgical or other invasive
procedure is considered to be the wrong procedure if it is not consistent with
the correctly documented informed consent for that patient
CMS has also addressed “never events” through the Hospital Inpatient
Prospective Payment System. Medicare will not longer pay a hospital a higher
rate for an inpatient stay if the sole reason for the enhanced stay/payment is
one of a specified group of hospital-acquired conditions.
The Joint Commission has addressed the issue by developing Universal Protocols for
Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. The three
principal components of the Universal Protocol are:
- Conducting a pre-procedure verification process
- Marking the procedure site, and
- Taking a “time out” before starting the procedure.
In 2012, a new weapon in the critical fight to reduce
the incidence of wrong site surgery became available, the Targeted Solutions
Tool (TST). Developed by the Joint Commission Center for Transforming Healthcare, the TST
guides healthcare organizations through a step-by-step process to identify,
measure and reduce risks in key processes that can contribute to a wrong site
surgery. For more information, refer to Center for Transforming Healthcare.