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  • Measure Summary
  • NQMC:004982
  • Feb 2009

Prevention of wrong-site or wrong-patient surgery: does the hospital have a protocol for prevention of wrong-site or wrong-patient surgery?

Ministry of Health. Safe practices indicators project: background, summary of methods and measurement strategies. Madrid: Ministry of Health; 2009 Feb 20. 97 p.

This is the current release of the measure.

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

Primary Measure Domain

Clinical Quality Measures: Structure

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to determine whether or not the hospital has a protocol for prevention of wrong-site or wrong-patient surgery.

Rationale

Similarity of patient names and other characteristics and symmetry between the two sides of the body present many opportunities for wrong-site errors or wrong-patient errors. These errors often result in significant adverse events, events that are now believed to be far more common than previously recognized.

The existence of a protocol in this respect reflects the hospital's endeavors to reduce adverse events related to wrong-site or wrong-patient surgery.

Evidence for Rationale

Ministry of Health. Safe practices indicators project: background, summary of methods and measurement strategies. Madrid: Ministry of Health; 2009 Feb 20. 97 p.

Primary Health Components

Wrong-site surgery; wrong-patient surgery; protocol for prevention

Denominator Description

This measure applies to hospitals (one hospital at a time).

Numerator Description

The hospital has a protocol for prevention of wrong-site or wrong-patient surgery (see the related "Numerator Inclusions/Exclusions" field).

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

80% of hospitals (2008 data) do not have protocol to prevent wrong-site or wrong-patient procedures.

Evidence for Additional Information Supporting Need for the Measure

Ministerio de Sanidad y Consumo. Indicadores de buenas practicas sobre seguridad del paciente. Resultados de su medicion en una muestra de hospitales del sistema nacional de salud Español. Madrid: Ministerio de Sanidad y Consumo; 2008. 95 p.

Extent of Measure Testing

After pilot testing, the set of indicators has been measured in a random sample of 25 Spanish hospitals, stratified by hospital size. The main objective has been to field test the feasibility of measurement in the various settings representing real life situations in the context of the Spanish Health Care System.

Both the whole indicators validation report and the results of the baseline measurement in a sample of the Spanish National Health Service (NHS) hospitals may be accessed and downloaded from the Spanish Ministry of Health web page (in Spanish):

Evidence for Extent of Measure Testing

Ministerio de Sanidad y Consumo. Construccion y validacion de indicadores de buenas practicas sobre seguridad del paciente. Madrid: Ministerio de Sanidad y Consumo; 2008. 178 p.

Ministerio de Sanidad y Consumo. Indicadores de buenas practicas sobre seguridad del paciente. Resultados de su medicion en una muestra de hospitales del sistema nacional de salud Español. Madrid: Ministerio de Sanidad y Consumo; 2008. 95 p.

Ministry of Health. Safe practices indicators project: background, summary of methods and measurement strategies. Madrid: Ministry of Health; 2009 Feb 20. 97 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Hospital Inpatient

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Does not apply to this measure

Target Population Gender

Does not apply to this measure

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Does not apply to this measure

Denominator Sampling Frame

Health care or public health organization

Denominator (Index) Event or Characteristic

Does not apply to this measure

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
This measure applies to hospitals (one hospital at a time).

Exclusions
None

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
The hospital has a protocol for prevention of wrong-site or wrong-patient surgery.

Request copy of document and assess whether or not it includes:

  • Wrong site
  • Wrong patient
  • Determine whether or not the protocol is in use in all surgical units

Exclusions
None

Numerator Search Strategy

Fixed time period or point in time

Data Source

Organizational policies and procedures

Provider characteristics

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

None

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Dichotomous

Interpretation of Score

Desired value is presence of a characteristic

Allowance for Patient or Population Factors

Does not apply to this measure

Standard of Comparison

Internal time comparison

Original Title

Existence of a protocol for prevention of wrong-site or wrong-patient surgery.

Measure Collection Name

Safe Practices Indicators Project

Measure Set Name

Facilitating Information Transfer and Clear Communication

Measure Subset Name

Prevention of Wrong-site or Wrong-patient Procedure

Submitter

Spanish Agency for Healthcare Quality of the Spanish Ministry of Health

Developer

Grupo de Investigación sobre Gestión de la Calidad en Servicios de Salud, University of Murcia, under contract to the Spanish Ministry of Health

Funding Source(s)

Agency for Quality, Spanish Ministry of Health

Composition of the Group that Developed the Measure

Saturno, Pedro J., MD, DrPH; Group Director and Project PI

Castillo, Carmen; López, M. José; Ramón, Teresa; Nurses

Carrillo, Andrés, MD; Intensive Care Specialist

Iranzo, M. Dolores; Hospital pharmacist

Soria, Victor, MD; Surgeon

Parra, Pedro, MD; Gomis, Rafael, MD; Gascón, Juan J., MD; Quality Management Specialists

Financial Disclosures/Other Potential Conflicts of Interest

Project entirely financed by the Spanish Ministry of Health.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2009 Feb

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

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

Source(s)

Ministry of Health. Safe practices indicators project: background, summary of methods and measurement strategies. Madrid: Ministry of Health; 2009 Feb 20. 97 p.

Measure Availability

Source not available electronically.

For more information, contact:

  • Ministry of Health and Social Policy, at Paseo del Prado, 18-20, planta baja, esquina con Lope de Vega. 28014 Madrid; Phone: +34 901 400 100; Fax: +34 915 96 44 80; Web site: www.msc.es/en/home.htm External Web Site Policy.

    OR

  • Pedro J. Saturno, Facultad de Medicina, at Universidad de Murcia, 30100 Espinardo-Murcia (Spain); Phone: 868 883 948; Fax: +34 868 883947; E-mail: psaturno@um.es; Web site: http://www.calidadsalud.com External Web Site Policy.

Companion Documents

The following are available:

  • Ministerio de Sanidad y Consumo. Construccion y validacion de indicadores de buenas practicas sobre seguridad del paciente. Madrid: Ministerio de Sanidad y Consumo; 2008. 178 p. This document is available in Portable Document Format (PDF) from the Ministry of Health and Social Policy Web site External Web Site Policy (in Spanish).
  • Ministerio de Sanidad y Consumo. Indicadores de buenas practicas sobre seguridad del paciente. Resultados de su medicion en una muestra de hospitales del sistema nacional de salud Español. Madrid: Ministerio de Sanidad y Consumo; 2008. 95 p. This document is available in PDF from the Ministry of Health and Social Policy Web site External Web Site Policy (in Spanish).

NQMC Status

This NQMC summary was completed by ECRI Institute on August 21, 2009. The information was verified by the measure developer on October 16, 2009.

This NQMC summary was retrofitted into the new template on July 27, 2011.

The information was reaffirmed by the measure developer on April 4, 2016.

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