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  • Measure Summary
  • NQMC:009659
  • Mar 2014

Perioperative protocol: percentage of wrong surgery events per month.

Card R, Sawyer M, Degnan B, Harder K, Kemper J, Marshall M, Matteson M, Roemer R, Schuller-Bebus G, Swanson C, Stultz J, Sypura W, Terrell C, Varela N. Perioperative protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Mar. 124 p. [124 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Danielson D, Bjork K, Card R, Foreman J, Harper C, Roemer R, Stultz J, Sypura W, Thompson S, Webb B. Preoperative evaluation. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 61 p.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Clinical Quality Measures: Outcome

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of wrong surgery events per month.

Rationale

The priority aim addressed by this measure is to eliminate the wrong surgical procedure or surgery performed on the wrong body part or on the wrong patient.

Evidence for Rationale

Card R, Sawyer M, Degnan B, Harder K, Kemper J, Marshall M, Matteson M, Roemer R, Schuller-Bebus G, Swanson C, Stultz J, Sypura W, Terrell C, Varela N. Perioperative protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Mar. 124 p. [124 references]

Primary Health Components

Perioperative protocol; wrong surgery event/procedure

Denominator Description

Total number of surgical cases per month (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of wrong surgery events per month (see the related "Numerator Inclusions/Exclusions" field)

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory Procedure/Imaging Center

Hospital Inpatient

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

All ages

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Staying Healthy

IOM Domain

Effectiveness

Safety

Case Finding Period

The time frame pertaining to data collection is a calendar month, but three months could be consolidated into quarterly data points, as well, if case load and/or event numbers are small.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Total number of surgical* cases per month

Population Definition: Patients of all ages who have a surgical procedure performed.

Data Collection: Event data should be reported through an incident or sentinel event report or follow the hospital's policy for reporting. Total surgical cases can be collected through the surgical schedule, log, or hospital billing.

*Surgery is defined as an invasive procedure** that takes place in an operating/procedure room by surgeon.

**Invasive Procedure: Any procedure that exposes the patient to more than minimal risk. This includes, but is not limited to, any entry, puncture or insertion of an instrument or foreign material into tissues, cavities or organs. This applies to any procedure performed in settings such as special procedure units, rooms or clinics, or at the patient's bedside. These procedures may involve moderate or deep sedation. Generally, this includes procedures requiring consent by the patient. This excludes venipuncture, intravenous therapy, nasogastric tube insertion, Foley catheters, flexible sigmoidoscopy, and vaginal exams (Pap smears).

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of wrong surgery events* per month

*Wrong surgery event is defined as a wrong surgical procedure, a surgical procedure performed on the wrong patient, or a surgical procedure performed on the wrong side, site, or level.

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Paper medical record

Other

Type of Health State

Adverse Health State

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Number of wrong surgery events per month.

Measure Collection Name

Perioperative Protocol

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Composition of the Group that Developed the Measure

Work Group Members: Randall Card, MD (Work Group Leader) (Cuyuna Regional Medical Center) (Family Medicine); Mark Sawyer, MD (Work Group Leader) (Mayo Clinic) (Trauma and Emergency Surgery); William Sypura, MD (Fairview Health Services) (Family Medicine); Mary Matteson, RN, BA (Gillette Children's Specialty Healthcare) (Surgery); Gwen E. Schuller-Bebus, RN, MA (Gillette Children's Specialty Healthcare) (Surgery); Cheryl Swanson (Gillette Children's Specialty Healthcare) (Patient Safety and Quality); Jerry Stultz, MD (HealthPartners Medical Group and Regions Hospital) (Pediatrics); Rebekah Roemer, PharmD, BCPS (Park Nicollet Health Services) (Pharmacy); Kathleen Harder, PhD (University of Minnesota) (Human Factors Content Consultant); Carrie Terrell, MD (University of Minnesota) (OB/GYN); Nicole Varela, MD (Winona Health) (Anesthesiology); Barb Degnan, RN, BSN (Patient Representative); Jill Kemper, MA (Institute for Clinical Systems Improvement [ICSI]) (Project Manager); Melissa Marshall, MBA (ICSI) (Project Manager)

Financial Disclosures/Other Potential Conflicts of Interest

The Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols.

In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report Clinical Practice Guidelines We Can Trust (2011).

Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.

The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site External Web Site Policy.

Disclosure of Potential Conflicts of Interest

Randall Card, MD, FAAP – Work Group Leader
Family Medicine, Cuyuna Regional Medical Center
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Barb Degnan, RN, BSN – Work Group Member
Patient Representative, ICSI Patient Advisory Council
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Kathleen Harder, PhD – Work Group Member
Human Factors Content Consultant, University of Minnesota
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: ICSI Prevention of Unintentionally Retained Foreign Objects
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Mary Matteson, RN, BA – Work Group Member
Charge Nurse, OR Circulator/Scrub, Gillette Children's Specialty Healthcare
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Rebekah Roemer, PharmD, BCPS – Work Group Member
Pharmacy, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Mark D. Sawyer, MD – Work Group Leader
Consultant, Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Gwen E. Schuller-Bebus, RN, MA – Work Group Member
Nurse Manager, Surgical & Peri Anesthesia Services, Gillette Children's Specialty Healthcare
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Jerry Stultz, MD – Work Group Member
Pediatrics, Health Partners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Reviewed image charts for TREC Med information retrieval project through Oregon Health and Science University

Cheryl Swanson – Work Group Member
Clinical Facilitator, Patient Safety and Quality, Gillette Children's Specialty Healthcare
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

William Sypura, MD – Work Group Member
Family Medicine, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Carrie Terrell, MD – Work Group Member
Assistant Professor, Chief of Staff UMMC, Medical Director WHS, University of Minnesota
National, Regional, Local Committee Affiliations: University of Minnesota Physicians Board Member, MN ACOG Advisory Committee
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Nicole Varela, MD – Work Group Member
Anesthesiology, Winona Health
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2014 Mar

Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

This is the current release of the measure.

This measure updates a previous version: Danielson D, Bjork K, Card R, Foreman J, Harper C, Roemer R, Stultz J, Sypura W, Thompson S, Webb B. Preoperative evaluation. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 61 p.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Card R, Sawyer M, Degnan B, Harder K, Kemper J, Marshall M, Matteson M, Roemer R, Schuller-Bebus G, Swanson C, Stultz J, Sypura W, Terrell C, Varela N. Perioperative protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Mar. 124 p. [124 references]

Measure Availability

Source available for purchase from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy. Also available to ICSI members for free at the ICSI Web site External Web Site Policy and to Minnesota health care organizations free by request at the ICSI Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on July 20, 2010.

This NQMC summary was retrofitted into the new template on July 22, 2011.

This NQMC summary was updated by ECRI Institute on August 31, 2011, June 12, 2013 and again on November 3, 2014.

The information was reaffirmed by the measure developer on January 13, 2016.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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NGC GUIDELINE SUMMARIES

  • NGC:010503
  • 1997 Sep (revised 2014 Mar)

Perioperative protocol. Health care protocol.


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