Did you know this?
The Joint Commission Board of Commissioners originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ in July 2003, and it became effective July 1, 2004 for all accredited hospitals, ambulatory care and office-based surgery facilities.
Implementation of this standard was observed in the breach for some time. One article notes: "The rate of wrong-site surgical procedures before and after implementation of the Universal Protocol mandate was not significantly different."
So penalties were imposed. Wrong-site surgeries were declared "never" events. As such, doctors and hospitals cannot be paid when they occur. How effective has this been at reducing the number that occur? Not much or at all.
Understanding that rule-based failures--actions that match intentions but do not achieve their intended outcomes due to incorrect application of a rule or inadequacy of the plan--are always possible, it still makes sense to pursue universal application of the "universal" protocol.
Here's an additional idea that could be implemented immediately by all of the malpractice insurance companies in the country: Any surgeon who has carried out a wrong-site surgery who did not follow the universal protocol for a time-out would not be covered for malpractice claims on that procedure. Any anesthesiologist who was attending such a surgery likewise would not be covered for malpractice claims on that procedure.
Maybe this would finally start to make a difference in the frequency of wrong-site surgeries. What do you think of this idea?
The Joint Commission Board of Commissioners originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ in July 2003, and it became effective July 1, 2004 for all accredited hospitals, ambulatory care and office-based surgery facilities.
Implementation of this standard was observed in the breach for some time. One article notes: "The rate of wrong-site surgical procedures before and after implementation of the Universal Protocol mandate was not significantly different."
So penalties were imposed. Wrong-site surgeries were declared "never" events. As such, doctors and hospitals cannot be paid when they occur. How effective has this been at reducing the number that occur? Not much or at all.
Understanding that rule-based failures--actions that match intentions but do not achieve their intended outcomes due to incorrect application of a rule or inadequacy of the plan--are always possible, it still makes sense to pursue universal application of the "universal" protocol.
Here's an additional idea that could be implemented immediately by all of the malpractice insurance companies in the country: Any surgeon who has carried out a wrong-site surgery who did not follow the universal protocol for a time-out would not be covered for malpractice claims on that procedure. Any anesthesiologist who was attending such a surgery likewise would not be covered for malpractice claims on that procedure.
Maybe this would finally start to make a difference in the frequency of wrong-site surgeries. What do you think of this idea?