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Wrong-site surgical malpractice: the ultimate "never event."

In previous posts we discussed plans that Medicaid has to stop paying for certain Boston medical malpractice incidents called "never events." The Agency for Healthcare Research and Quality has adopted the term "never event" which was originally introduced by the former CEO of the National Quality Forum. The term "never event" describes an egregious medical malpractice mistake that should never happen.

The list of what qualifies as a "never event" has expanded to include events that are unambiguous, serious, and typically preventable, such as wrong-site surgery. Wrong-site surgery is the most common type of "never event" and approximately 13 percent of medical mistakes reported to the Joint Commission were wrong-site surgeries. The Joint Commission is the accrediting body of the country's hospitals.

The president of the Joint Commission introduced a new set of mandatory rules aimed at preventing wrong-site surgeries. The rules were supposed to help end the frequency of wrong-site surgeries by requiring doctors to mark the site of surgery, take a team break before surgery, and verify that the right patient was on the operating table.

Unfortunately, the Washington Post reports that the occurrence of wrong-site surgeries has only increased in the past 7 years and these errors occur approximately 40 times every week in hospitals around the country. The Joint Commission is not aware of many of these incidents because reporting to the commission is voluntary. About 49 cases were reported to the commission in 2004 and this number has jumped to 93 cases reported in 2010.

In our next post we will discuss the reaction to these statistics and what doctors are planning to do to change the problem of wrong-site surgeries.

Source: The Washington Post, "The Pain of Wrong Site Surgery," Sandra G. Boodman, 6/20/11

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