01.25.2023
Claim Study
How To Deal With Non-Compliant Patients
What happens when a physician sees a patient who does not follow medical advice or treatment instructions? How to deal wi...
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This year marks 15 years since The Joint Commission established a “Universal Protocol,” mandatory safety standards to prevent wrong-site, wrong-procedure and wrong-patient surgery. Despite the many years Universal Protocol has been in effect, claims continue to be filed alleging these surgical “never events.” The Agency for Healthcare Research and Quality defines a never event as a “particularly shocking medical error—such as wrong-site surgery—that should never occur.”
In the most recent headline dated March 2019, a Tennessee patient filed a lawsuit alleging her surgeon placed a stent in the wrong kidney, resulting in damage leading to her need for long-term dialysis. These claims also occur closer to home, with wrong operative side (right v. left) being especially vulnerable. Often, the “perfect storm” of process failures must happen in order to reach the patient, but these events still unfortunately occur.
Looking back through the claims history of the Trust Funds, there are several cases of wrong-site surgery involving fingers, hands, knees, ovaries and even the brain. In one case, a 27-year-old female with constant stomach/pelvic pain was admitted for the removal of a dermoid cyst on her right ovary. The left ovary was removed instead. The hospital’s root cause analysis found multiple contributing factors. The procedural consent form stated only “removal of ovary” and did not specify left or right. Additionally, the surgical site was not marked and several position changes by surgeon, tech and relief staff may have caused confusion.
Universal Protocol consists of three parts:
According to the Joint Commission Center for Transforming Healthcare, process errors resulting in wrong-site surgeries can occur in multiple areas:
Considering the above root causes, can you or your team identify weaknesses in your facility’s compliance with Universal Protocol? What action can your facility take to bring Universal Protocol back into focus and proactively reduce risk?
From the clinical perspective, conducting a thorough review of your facility’s Universal Protocol process can be the first step in identifying opportunities to decrease the risk of wrong-site, wrong-procedure or wrong-person surgery. A thorough review can be conducted through the FMEA, Six Sigma or Lean Six Sigma processes. Consider these guidelines when reviewing the Universal Protocol process:
Reviewing your facility’s current process is a proactive way to identify opportunities and improve the Universal Protocol process within your organization.
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