Never Events: Wrong Site Surgery

Current Patient Safety Initiatives Impacting Foot and Ankle Surgeons

  • 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 patient.

      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

Educational Opportunities

Upcoming