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## Complete Summary

#### TITLE

Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC)
admissions who experienced a wrong site, wrong side, wrong patient,
wrong procedure, or wrong implant.

#### SOURCE(S)

ASC Quality Collaboration. ASC quality measures: implementation guide.
Version 1.2. Ambulatory Surgery Center; 2008 Apr. 18 p.

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Outcome

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the percentage of Ambulatory Surgery
Center (ASC) admissions who experienced a wrong site, wrong side, wrong
patient, wrong procedure, or wrong implant.

#### RATIONALE

\"Surgery performed on the wrong body part,\" \"surgery performed on the
wrong patient,\" and \"wrong surgical procedure performed on a patient\"
have all been endorsed as serious reportable surgical events by the
National Quality Forum (NQF). This outcome measure serves as an indirect
measure of providers\' adherence to the Joint Commission\'s \"Universal
Protocol\" guideline for eliminating wrong site, wrong procedure, wrong
person surgery. The Universal Protocol is based on the consensus of
experts and is endorsed by more than forty professional medical
associations and organizations. In order to encompass the outcomes of
all key identification verifications, the Ambulatory Surgery Center
(ASC) Quality Collaboration\'s measure incorporates not only wrong site,
wrong side, wrong patient and wrong procedure, but also wrong implant in
its specifications.

#### PRIMARY CLINICAL COMPONENT

Ambulatory Surgery Center (ACS); admissions experiencing a wrong site,
wrong side, wrong patient, wrong procedure, or wrong implant

#### DENOMINATOR DESCRIPTION

All Ambulatory Surgery Center (ASC) admissions

#### NUMERATOR DESCRIPTION

All Ambulatory Surgery Center (ASC) admissions experiencing a wrong
site, wrong side, wrong patient, wrong procedure, or wrong implant (see
the related \"Numerator Inclusions/Exclusions\" field in the Complete
Summary)

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Unspecified

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement

### Application of Measure in its Current Use

#### CARE SETTING

Ambulatory Care

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Single Health Care Delivery Organizations

#### TARGET POPULATION AGE

Unspecified

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

\"JCAHO reviewed voluntary reports of 1152 \'sentinel events\' from 1995
to 2001. Wrong-site surgery accounted for 114 (9.9%) of these reports
and included procedures in neurosurgery, urology, orthopedics, and
vascular surgery. Despite the high profile of JCAHO\'s Sentinel Event
Policy, it is believed that under-reporting by healthcare organizations
apparently affects these statistics. Only 66 percent of the 1152 total
events were self-reported by the institutions involved. The remainder
came from patient complaints, media stories and other sources. Using a
mandatory reporting system, the New York State Department of Health
received 46 reports of wrong-site surgery from 1998 through 20004
compared with the 114 cases JCAHO received nationally over a period 3
times longer, suggesting that voluntary incident reporting may
underestimate the true incidence by a factor of 20 or greater.

The Physicians Insurers Association of America (PIAA) reviewed claims
data from 22 malpractice carriers representing 110,000 physicians from
1985 to 1995. These claims included 331 cases of wrongsite surgery. The
complete PIAA database documents almost 1000 closed malpractice claims
involving wrong-site surgery. However, this figure also underestimates
the prevalence of wrong-site surgery, as every case does not result in a
claim. Most wrong-site surgeries involve relatively minor procedures
such as arthroscopy, rather than limb amputations or major neurosurgical
procedures. Consequently sequelae are minimal. The State Volunteer
Mutual Insurance Company (Tennessee) released a series of 37 wrong-site
surgery claims from 1977 to 1997. Performing the correct procedure on
the wrong side constituted the most common error (e.g., arthroscopic
knee surgery on the wrong knee in 15 of the 37 cases). 26 of the
patients experienced no sequelae beyond a scar, and only three patients
suffered permanent disability. Given the rarity of significant harm,
estimates of the incidence of wrong-site surgery derived from litigation
data likely underestimate the true prevalence of this problem, as do
estimates based on incident reports.\"

#### EVIDENCE FOR INCIDENCE/PREVALENCE

Agency for Healthcare Research and Quality (AHRQ). Making healthcare
safer. A critical analysis of patient safety practices. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); Chapter 43.2 -
strategies to avoid wrong site surgery.

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

Unspecified

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Safety

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

All Ambulatory Surgery Center (ASC) admissions

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All Ambulatory Surgery Center (ASC) admissions

**Exclusions**\
None

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Institutionalization

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All Ambulatory Surgery Center (ASC) admissions\* experiencing a
wrong\*\* site, wrong side, wrong patient, wrong procedure, or wrong
implant

\**Admission*: Completion of registration upon entry into the facility.

\*\**Wrong*: Not in accordance with intended site, side, patient,
procedure or implant.

**Exclusions**\
None

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Encounter or point in time

#### DATA SOURCE

Administrative data\
Medical record\
Special or unique data

#### LEVEL OF DETERMINATION OF QUALITY

Individual Case

#### OUTCOME TYPE

Adverse Outcome

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a lower score

#### ALLOWANCE FOR PATIENT FACTORS

Unspecified

#### STANDARD OF COMPARISON

External comparison at a point in time\
External comparison of time trends\
Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

After refining these standardized measures, the Ambulatory Surgery
Center (ASC) Quality Collaboration (QC) piloted them in a sample of ASCs
and was able to confirm their feasibility and usability. On November 15,
2007, five ASC facility-level measures were endorsed by the National
Quality Forum (NQF) after having gone through rigorous evaluation and
consensus building.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

ASC Quality Collaboration. ASC quality measures: implementation guide.
Version 1.2. Ambulatory Surgery Center; 2008 Apr. 18 p.

### Identifying Information

#### ORIGINAL TITLE

Wrong site, wrong side, wrong patient, wrong procedure, wrong implant.

#### MEASURE COLLECTION

[Ambulatory Surgery Center (ASC) Quality
Measures](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=2037&doc=12487)

#### DEVELOPER

Ambulatory Surgery Center (ASC) Quality Collaboration

#### FUNDING SOURCE(S)

Unspecified

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

Unspecified

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

Unspecified

#### ENDORSER

National Quality Forum

#### ADAPTATION

Measure was not adapted from another source.

#### RELEASE DATE

2008 Apr

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

ASC Quality Collaboration. ASC quality measures: implementation guide.
Version 1.2. Ambulatory Surgery Center; 2008 Apr. 18 p.

#### MEASURE AVAILABILITY

The individual measure, \"Wrong Site, Wrong Side, Wrong Patient, Wrong
Procedure, Wrong Implant,\" is published in \"ASC Quality Measures:
Implementation Guide. Version 1.2.\" This document is available in
Portable Document Format (PDF) from the [Ambulatory Surgery Center
Quality Collaboration Web
site](http://www.ascquality.org/documents/ASCQualityCollaborationImplementationGuide.pdf).

#### NQMC STATUS

This NQMC summary was completed by ECRI Institute on September 10, 2008.
The information was verified by the measure developer on December 3,
2008.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### Disclaimer

#### NQMC DISCLAIMER

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© 2008 National Quality Measures Clearinghouse

Date Modified: 12/22/2008