Practice of Medicine


Surgical Provider Preventable Conditions

For more than ten years, considerable attention and effort has been devoted to reducing the number of surgical Provider Preventable Conditions (PPCs). Once part of the so-called “never events,” a term that the National Quality Forum and the Center for Medicare & Medicaid Services no longer uses in official communications, PPCs include wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) as well as retained foreign bodies. Since no standardized process was universally employed prior to 2002, the goal was that the implementation of a single protocol would drastically reduce the number of “wrong” occurrences and increased attention on retained surgical objects would also minimize these risks.

So How Have We Done?

Unfortunately, a recent report showed that these events have continued. Published in the online jour-nal, Surgery1, researchers from Johns Hopkins analyzed medical liability data from the National Practi-tioner Data Bank and estimated the nationwide rates of PPCs. Their data suggests that these occur at least 80 times per week in the United States, roughly half of which are WSPEs, and the other half being retained object incidents. Our experience indicates that these events continue to be reported, not just inside the operating room, but also in other health care settings including the emergency department, the radiology department and the office setting.

Available Tools

Given that implementation of the recommended practices to reduce these events (including marking of the incision by the surgeon, confirmation with the patient, and the pre-surgical time-out) is essentially universal now, it remains unclear why we have not been able to substantially reduce the occurrence rate. In response to this challenge, The Joint Commission has developed a “Targeted Solutions Tool” that hospitals can use to improve operating room processes and address repeated adverse occurrences. This tool is available at

The Importance of Safety Culture

Ultimately, effective behavior change to reduce these errors will derive from an understanding of sys-tems and the role that each provider plays in them. Systems work most efficiently when each member of the surgical team commits to the importance of that system, understands and carries out his or her role, and continuously works to evaluate results and improve the system. This requires strong leadership and commitment of resources to address problems. It also applies to the reduction of retained surgical ob-jects. Technology, such as radio-frequency identification (RFID) tags or barcode scanners attached to sponges, is becoming available and has been shown to lower the likelihood of surgical items being re-tained.

In addition, procedures which are at higher risk for retained surgical objects have been identified, in-cluding emergency procedures, longer procedures, those involving staff changes and those with patients who are morbidly obese. These should be targeted for greater scrutiny because of the increased risk of retained surgical objects at the end of the procedure.

Successful reduction of the risk to our patients of these preventable errors relies on the commitment of each provider to the systems that can prevent them, and working as a team to continually improve our performance.

1 Surgery. April 2013; 153(4): 465-472 2 Archives of Surgery. 2010; 145 (10): 978-984

Created by MagMutual from materials provided by COPIC as part of MagMutual and COPIC’s alliance to improve patient safety and quality of care for all of our PolicyOwners.


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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.