R E V I E W S & A N A LY S E S Process Assessment is Key to Prevention of Certain Ophthalmology Events Mary C. Magee, MSN, RN, CPHQ, CPPS INTRODUCTION Senior Patient Safety/Quality Analyst Pennsylvania Patient Safety Authority In 2015, representatives of the Betsy Lehman Center (The Center) for Patient Safety, a non-regulatory Massachusetts state agency, contacted the Pennsylvania Patient Safety ABSTRACT Authority about cataract-surgery events in Massachusetts hospitals and ambulatory surgi- cal facilities. The Center staff were interested in comparing Massachusetts’ trends with An estimated 24 million Americans have those in Pennsylvania. Of interest were the implantation of intraocular lenses (IOL) not cataracts, making cataract removal intended for the patient and wrong-site anesthesia eye injections; an increase in these and intraocular lens insertion one of types of errors had been reported to Massachusetts regulators the previous year. the most common surgeries performed in the United States. Cataract surgery Implantations of IOLs not intended for the patient and wrong-site anesthesia eye is safe, and serious injuries rarely injection events continue to be reported through the Pennsylvania Patient Safety occur. So when an increase in reports Reporting System (PA-PSRS). More than 4,300 events related to cataract procedures of Serious Events related to cataract were reported between July 2004 and June 2015. Although the overall number of IOL- procedures occurred in one year in related reports has been increasing since 2004, the number of incorrect lens implants Massachusetts, the Betsy Lehman has been decreasing and wrong-site eye injections have declined since 2004. Center for Patient Safety responded. There is sparse research for comparison; however, in a study of 106 “surgical confu- The Center collaborated with a number sions”* in ophthalmology in New York state over a 23-year period, the most common of state and professional agencies, confusions cited were wrong lens implant (63%) and injection of anesthesia into the formed an expert panel, and consulted incorrect eye (13%).1 The study further analyzed claims data for a five-year period with the Pennsylvania Patient Safety (2001–2005) and suggested an incidence of 69 surgical confusions per 1 million eye Authority. The Authority found that operations.1 from July 1, 2004, through June 30, Because of Pennsylvania’s adverse event database and broader scope of reporting 2015, Pennsylvania acute care facili- requirements, a comparison of trends of these types of events could prove useful to The ties reported 4,307 events related to Center for interpreting the Massachusetts’ serious reportable events (SREs)† data.2 The cataract procedures and 23 wrong-site inquiry prompted the Authority to perform an analysis related to implantation of IOLs anesthesia eye injections. Since July not intended for the patient and wrong-site anesthesia injections in Pennsylvania. 2004, reporting of intraocular lens pro- cedure–related events, which includes near misses and good catches, has METHODS steadily increased while the number of Analysts queried PA-PSRS for intraocular cataract–related events and events meeting incorrect intraocular lens implant events the criteria for wrong-site surgery‡ in acute care facilities (i.e., acute care hospitals, has decreased. The Authority estimates ambulatory surgical facilities) for the period July 1, 2004, through June 30, 2015. the incidence of cataract-related sur- This time frame is consistent with the Authority’s previously published wrong-site gical confusions in Pennsylvania at surgery analyses and aligns with the time frame of procedure data available from the 61.8 per 1 million procedures for the Pennsylvania Health Care Cost Containment Council (PHC4). July 1, 2004, through June 30, 2015, Analysts individually reviewed the event report narratives and searched the cataract- period. In response to a rising trend related event details for the terms, “cataract,” “lens,” “IOL,” “wrong,” “incorrect,” of intraocular lens–related reports, “tear,” “pressure,” and “IOP.” increased vigilance towards prevention is necessary. Active participation by engaged staff in executing the Universal Protocol—including engaging the patient—and use of an ophthalmology- specific perioperative checklist remain the recommended best practices to * Surgical confusions were defined as: wrong implant, wrong-eye block, wrong patient or proce- prevent wrong eye identification, incor- dure, wrong eye, or wrong transplant. † rect lens implantation, and wrong-site Massachusetts mandates the reporting of Serious Reportable Events as defined by the National Quality anesthesia eye injections. (Pa Patient Saf Forum: http://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx Advis 2016 Sep;13[3]:92-99.) ‡ The definition used for the Authority’s wrong-site surgery program follows the National Quality Forum’s definition as outlined in the Serious Reportable Events In Healthcare—2011 Update: A Con- sensus Report. Page 92 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority Analysts requested a custom report RESULTS AND ANALYSIS event detail in sufficient quantity to make from PHC4* using Current Procedure Incorrect Intraocular Lens extrapolations possible. Terminology (CPT), Healthcare Common Implants Examples of reported incorrect IOL Procedure Code System (HCPCS), implants include the following:† The query resulted in 4,962 events; 4,307 supplementary classification of factors met the criteria for analysis related to cata- During the postoperative visit, the influencing health status and contact ract procedures. surgeon noted that the wrong IOL with health services (V-codes), and the International Statistical Classification of Of the 4,307 events power was inserted into the correct Diseases and Related Health Problems eye. When the causes were reviewed, —— 77 (1.8%) were associated with incor- (ICD-9) procedure codes for outpatient it was discovered that the surgeon rect IOL implants (i.e., not intended and inpatient eye and cataract procedures wrote the correct diopter lens on the for the patient) from July 2004 through June 2015. These patient’s medical record; however, —— 32 (0.7%) were associated with elec- the incorrect lens was selected by the data were analyzed and used to estimate tive lens exchanges rates and incidences for Pennsylvania. circulator. Additionally, the final —— 7 (0.2%) were associated with an verification had not been completed To estimate incidences of surgical confu- expired lens being implanted prior to start of procedure. sions in Pennsylvania commensurate with —— 1 (0.02%) was surgery performed on New York state claims data of Simon The patient was scheduled to have a the wrong eye cataract removal of the left eye with et al., a subset of PA-PSRS and PHC4 Although the number of IOL-related an IOL implant of diopter 12.0. data was analyzed for the five-year period reports has increased since 2004, the Instead the patient received a 23.5 of 2010 to 2014. This time frame was number of incorrect lens implants has diopter. The error was discovered selected because July 2004 was the first decreased (Figures 1 and 2). An analysis when the nurse was preparing the full month in which events were reported of wrong-site eye injection events revealed through PA-PSRS, it reflected the most that the annual number reported has † The details of the PA-PSRS event narratives recent five full years of PA-PSRS and also declined since 2004. The causes of in this article have been modified to preserve PHC4 data available at the time of this these events were not described in the confidentiality. study, and the coding adjustments were fully implemented (see Limitations). Figure 1. Number of Intraocular Lens Procedure-Related Events Reported by Academic Year* through PA-PSRS (N = 4,307) NUMBER OF EVENTS 700 631 * The Pennsylvania Health Care Cost Contain- ment Council (PHC4) is an independent state 600 agency responsible for addressing the problem 512 of escalating health costs, ensuring the quality 500 448 of health care, and increasing access to health 517 526 care for all citizens regardless of ability to pay. PHC4 has provided data to the Authority in 400 345 an effort to further PHC4’s mission of edu- 303 300 263 338 cating the public and containing health care costs in Pennsylvania. PHC4, its agents, and staff have made no representation, guaran- 200 250 tee, or warranty, express or implied, that the 174 data – financial, patient, payor, and physician 100 specific information – provided to this entity, are error-free, or that the use of the data will 0 avoid differences of opinion or interpretation. * 6 7 8 9 0 1 2 3 4 5 5 -0 -0 -0 -0 -1 -1 -1 -1 -1 -1 -0 This analysis was not prepared by PHC4. This 05 06 07 08 09 10 11 12 13 14 04 20 20 20 20 20 20 20 20 20 20 analysis was done by the Pennsylvania Patient 20 Safety Authority. PHC4, its agents and staff, MS16590 bear no responsibility or liability for the results ACADEMIC YEAR of the analysis, which are solely the opinion of this entity. * July 2004 was the first full month in which events were reported through PA-PSRS. Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 93 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 2. Incorrect Intraocular Lens Implants (N = 77) and Wrong-Site Anesthesia contributing to or resulting in temporary Eye Injections involving Cataract Procedures (n = 8) Reported through PA-PSRS by harm (E-F) and required either treatment Academic Year* or intervention or initial or prolonged hospitalization. NUMBER OF EVENTS 14 Facility The majority of events, 51 (66.2%), were 12 reported by ambulatory surgical facilities, 2 0 where most lens-implant procedures are 10 1 2 10 10 performed. 8 9 9 1 1 0 0 Wrong-Site Anesthesia Eye 6 7 8 0 Injections 0 61 6 6 1 4 5 5 The PA-PSRS query resulted in 23 4 event reports that met the criteria for a 2 4 wrong-site event. Nineteen (82.6%) were associated with wrong-side anesthesia 0 injections (i.e., wrong eye identified) and 5* 6 7 8 9 0 1 2 3 4 5 4 (17.4%) were associated with unintended -0 -0 -0 -0 -1 -1 -1 -1 -1 -1 -0 05 06 07 08 09 10 11 12 13 14 04 anesthesia injections of the correct eye; for 20 20 20 20 20 20 20 20 20 20 20 example, the following errors were found: ACADEMIC YEAR —— Re-injection of an anesthetic instead Incorrect intraocular lens implants Wrong-site anesthesia eye injections MS16591 of an antibiotic cataract procedures —— Injection of the wrong concentration * July 2004 was the first full month in which events were reported through PA-PSRS. and mixture of an anesthetic —— Injection of the wrong anesthetic OR suite for the next surgery. The lens strength, type, size, or other as being —— Injection of the anesthetic prior to patient was returned to the operating incorrect (these data are not mutually marking the pupil room for insertion of the correct lens. exclusive). Of the 44: Discipline and Type of Anesthesia Detection —— 33 (75.0%) reports mentioned the Injection Of the 77 incorrect IOL implant events: lens power Analysts reviewed the event detail of —— 9 (20.5%) reports mentioned two or the reported events to determine which —— 53 (68.8%) mentioned when the disciplines performed the injection and more lens-related items error was detected what types of anesthesia injection were —— 8 (18.2%) reports mentioned the * 34 (64.2%) of the events were involved. The majority, 17 (73.9%) of lens type discovered on the day of surgery the 23, were performed by a surgeon, —— 5 (11.4%) reports mentioned the * 19 (35.8%) of the events were and 6 (26.1%) were performed by an lens size discovered after the day of sur- anesthesiologist. gery (e.g., post-operative visit in —— 1 (2.3%) report mentioned lens the physician’s office) displacement or other effect and was * The Authority’s event-reporting system uses classified as Other —— 48 (62.3%) reports indicated that an adaptation of the National Coordinating the patient returned to the operating Harm Council for Medication Error Reporting and Prevention harm index and the Veterans’ room or had an additional procedure Analysts reviewed the 77 events by harm Administration National Center for Patient performed score.* Figure 3 shows the percentage of Safety severity assessment code system to distin- Lens Characteristics IOL implantation events not intended guish between harm and no-harm events. The for the patient by harm score. Thirty- Pennsylvania Patient Safety Authority Harm Analysts reviewed the 77 events involv- Score Taxonomy is available exclusively online four (44.2%) were reported as an unsafe ing incorrect IOL implants. Forty-four at http://patientsafetyauthority.org/ condition (A-D) or no harm event, and ADVISORIES/AdvisoryLibrary/2015/ (57.1%) of the 77 reports mentioned the 43 (55.8%) events were reported as mar;12(1)/PublishingImages/taxonomy.pdf Page 94 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority Figure 3. Incorrect Intraocular Lens Implant Events (N = 77) and Wrong-Site prior to the cataract removal, and the Anesthesia Injections (n = 23) by Harm Score Reported through PA-PSRS, July 1, correct eye was then anesthetized and 2004, through June 30, 2015 operated on. PERCENTAGE When the patient was asked which Incorrect intraocular lens implants eye he was having his cataract sur- 100 Wrong-site anesthesia eye injections gery on, he was unsure. The medical record was checked and confirmed the 90 left eye was to be operated on. The 80 patient suddenly became restless and began retching. It took several minutes 70 for the patient to settle down. During this time, the non-operative eye was 60 mistakenly marked, and the anesthe- 49.4 sia block was given to the incorrect 50 eye. This mistake was identified once 43.5 39.1 the patient arrived in the OR. The 40 correct eye was then anesthetized. 30 Surgical Procedure 22.1 16.9 17.4 Analysts reviewed the event detail of the 20 23 wrong-site injections to determine the 10 6.5 surgical procedure involved. A slight major- 2.6 2.6 ity (n = 12, 52.2%) mentioned the surgical 0.0 0.0 0.0 0.0 0 procedure performed and of those: A B1 B2 C D E F G H I —— 66.7% (n = 8) were cataracts MS16592 HARM SCORE —— 16.7% (n = 2) were vitrectomies —— 8.3% (n = 1) was an ectropion correction Of the 17 injections performed by a Of the six injections performed by an —— 8.3% (n = 1) was an endophthalmitis surgeon: anesthesiologist: See Figure 2 for the number of wrong-site —— 14 (82.4%) were wrong-side anes- —— Five (83.3%) were wrong-side injections of anesthesia involving cataract thesia blocks, of which 4 specifically anesthesia blocks of which four spe- procedures. mentioned the location cifically mentioned the location Patient Harm * Two were retrobulbar injections * Two were retrobulbar injections Analysts reviewed the 23 events by the * One was a posterior auricular * One was a periocular injection reported harm score. Figure 3 shows the injection * One was a peribulbar injection percentage of wrong-site eye injection * One was a peribulbar injection —— One (16.7%) was an injection of events by harm score. The majority, 19 —— Three (17.6%) were unintended-eye the anesthetic before the pupil was (82.6%), were reported as an unsafe con- injections administered in the cor- marked for the specific lens implant dition or no harm event. rect eye, of which one specifically (i.e., against standard procedure for Facility Type mentioned the location this facility) The majority of events, 12 (52.2%), were * One was an inferotemporal Examples of reported wrong-side anesthe- reported by hospitals. quadrant injection behind the sia injections include the following: limbus A patient was scheduled to have a DISCUSSION cataract removal. The surgeon per- National and State Statistics formed a block to the incorrect eye after verifying the incorrect eye with By current estimates 20 million to 24 the patient. The error was discovered million Americans have cataracts.3,4 Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 95 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S The National Eye Institute projects that 47.6 per 1 million cataract procedures Interstate Agency Cooperation cataracts will affect more than 38 million for a comparable five-year period (2010 The Center was established to coordinate Americans by 2030 and more than 50 through 2014). Cataract procedures make and strengthen patient safety efforts in million by 2050.4 Annually in the United up 86.1% of all eye procedures for this Massachusetts through data analysis, con- States and Pennsylvania, an average of 3 comparative time period.5 sumer engagement, communications, and million and 149,000 cataract procedures As noted, the reporting of IOL proce- sharing of best practices.11 are performed, respectively.4,5 In a 2006 dure–related events, including good In 2014, 11 serious reportable events study on wrong-site surgeries, Seiden and catches such as preoperative identification (SREs) related to cataract surgeries had Barach analyzed reports from four data- of incorrect eye or lens power docu- been reported to the Massachusetts bases spanning one year and determined mentation, has steadily increased since Department of Public Health. In a that “cataract procedures were the second reporting began in 2004. The overall review of data from the previous five most common wrong-site incidents.”6 increase in reporting may be related to a years, The Center discovered that “the Healthgrades reports that cataract removal corresponding increase in eye and cataract most frequent type of SRE associated is the number one procedure performed procedures in Pennsylvania.5 However, the with cataract surgery was implantation in the United States.7 Cataract surgery trend of incorrect IOL implant events and of the incorrect IOL.”8 “The panel deter- is safe, serious injury is rare, and most wrong-site anesthesia eye injections has mined that system failures appeared to patients report an improved quality of life gradually decreased. be involved in incidents that resulted in after the procedure.8,9 It is encouraging to note that Pennsylvania either implantation of IOLs not intended In Pennsylvania for the study period July 1, hospitals and ambulatory surgical facilities for the patient or wrong-site injections of 2004, through June 30, 2015, for which are reporting cataract-related Incidents. anesthesia.”12 The Center, working closely PHC4 procedure data are available, the This reporting trend suggests that facil- with the Massachusetts Department of incidence of surgical confusions is 61.8 per ity staff are learning from Incidents, the Public Health, the Massachusetts Society 1 million cataract procedures (see Table Authority’s equivalent of good catches and of Eye Physicians and Surgeons, and the for types of events). near misses, which is a characteristic of Massachusetts Society of Anesthesiologists, high reliability organizations. issued an advisory to hospitals and ambula- It is difficult to make comparisons tory surgery facilities informing them of or benchmarks because of the lack of In the Authority’s most recent pub- what was being reported, why they were standardized definitions and dearth of lished update on wrong-site eye surgery, being informed, what next steps were being research and statistics about intraopera- 174 events were related to anesthesia taken, and what the facilities could do tive cataract procedure events. Simon et blocks.10 Of those events, 23 (13.2%) to prevent patient harm.12 Additionally, al. used the number of eye procedures, were wrong-site anesthesia eye injections. The Center assembled an expert panel of not cataract procedures, and suggested an The Authority estimates an incidence of anesthesiologists, ophthalmologists, nurse incidence of 69 surgical confusions per 1 wrong-site anesthesia injections is 14.1 administrators, and patient advisors to ana- million eye operations in New York state.1 per 1 million cataract procedures in lyze the contributing factors to these events In comparison, the Authority estimates Pennsylvania for the period July 1, 2004, and to identify strategies to reduce risk.12 41.0 per 1 million eye procedures and through June 30, 2015. Similar to what was done in Massachusetts, in Pennsylvania, the Table. Incidence of Cataract-Related Surgical Confusion Events as Reported through the Authority identified reports of wrong-site Pennsylvania Patient Safety Reporting System in the state, July 1, 2004, through June 30, anesthesia eye injections and a wrong-site 2015 (N = 101) eye surgery events. In Pennsylvania the harm scores associated with these events INCIDENCE PER 1 MILLION CATARACT indicated a range from unsafe conditions TYPE OF EVENT NUMBER PROCEDURES to temporary patient harm. Incorrect intraocular lens implant 77 47.2 Risk Reduction Strategies Wrong-site anesthesia injection 23 14.1 Checklist Advocated Wrong eye surgery 1 0.6 Relying on memory alone to confirm Note: 1,633,039 = Number of cataract procedures performed in Pennsylvania, July 1, 2004, through June 30, 2015, provided by custom report from the Pennsylvania Health Care Cost Containment Council. surgical details can increase the likelihood 2016 Jun. of errors.13,14 In a study by Pikkel et al., Page 96 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority cataract surgeons attempted to identify Prevent Wrong-Site Surgery21 and the * Stay current on evidence-based the correct operative side without using a Self-Assessment Checklist for Program practices for minimizing the risk preoperative verification process. “Before Elements Associated with Preventing of patient harm from anesthesia entering the operating room (OR) sur- Wrong-Site Surgery.22 Previous Authority * Engage patients in decisions geons were asked to identify the correct publications on this topic have provided about anesthesia and sedation operative side by using only the patient’s best practices to decrease the likelihood of * Strengthen “onboarding” of new name and then upon entering the OR, implanting the incorrect lens or perform- and contracted anesthesia staff, the surgeons were asked to identify the ing wrong-site surgery.23,24 In response to including thorough credential- correct operative side by looking at the concerns that staff are just “going through ing, formalized orientations, and patient’s face standing near the patient the motions” of the Universal Protocol, observed eye block assessments but not close enough to see the dilated the Authority created and distributed pupil. The surgeons incorrectly identified a poster, titled Patients and Surgical Performance Improvement the operative side in 27% of the cases Teams Work Together to Avoid Wrong-Site Accrediting and licensing agencies require using name only and in 17% of the cases Surgery that engages the patient in the ongoing assessments of safety and quality looking at the patients’ faces.”15 confirmation process (http://patient- processes.26,27 Organization and medical safetyauthority.org/EducationalTools/ staff leadership may proactively conduct The use of a surgical checklist enhances PatientSafetyTools/PWSS/Documents/ periodic observational surveillance of the likelihood of identifying safety haz- poster_avoid%20wss.pdf).10 compliance with perioperative pro- ards.16,17,18 Simon asserts that the use cesses including the Universal Protocol. of the Universal Protocol would have Expert Panel Strategies Additionally, eligible providers can report prevented wrong-lens implants, wrong- The Center’s expert panel key recommen- quality-of-care compliance through the eye surgeries, and wrong-eye anesthesia dations to prevent wrong-lens, wrong-eye, Physician Quality Reporting System.28 blocks in 85% of the cases studied in New and wrong-patient errors and injuries York state.1 The American Academy of Should a wrong-site eye surgery or other related to ocular anesthesia appear Ophthalmology (AAO) convened a wrong adverse event or near miss occur, facility below.25* Please refer to the panel’s full site task force and in 2014 revised its rec- staff may benefit from studying the event report for details. ommendations for preventing wrong-site and analyzing the contributing factors ophthalmology surgery and updated its —— To prevent wrong-lens, wrong-eye, and root causes. Evaluating and reinforc- Ophthalmic Surgical Safety Checklist.19,20 and wrong-patient errors: ing successful processes may also be of AAO specifies steps to follow prior to the * Institute a formal lens manage- value.29 Collecting and analyzing data over day of surgery (e.g., the order for surgery ment policy that defines uniform time allows facilities to follow trends and and communication with surgery staff) processes for ordering, storing, measure improvements. The Authority and on the day of surgery (e.g., consent selecting, and verifying IOLs has a Wrong-Site Surgery Error Analysis process, hard stop empowerment, mark- * Adopt a uniform, facility-wide Form that provides a format to capture ing the operative eye in the preoperative policy for marking the operative “information about wrong-site surgery, eye, and perform a separate time- near misses, and actual occurrences” and 30 area, and the time-out).19 AAO also issued a list of special considerations for the vari- out prior to a nerve block a template for Gap Analysis and Action ous types of eye surgeries that depend on * Use multiple patient identifiers Plan to Prevent Wrong-Site Surgery; the preoperative calculations; for IOL surgery, and engage patients using active template allows facilities to compare recommendations include performing an verification surgical observations to evidence-based independent double check of IOL powers principles, goals, and measurement stan- * Perform robust time-outs before and documenting “patient’s name, eye, dards.31 Information learned from these every key step in the procedure and IOL power on a white board or taped analyses can be used to reduce safety haz- —— To prevent injuries related to ards, implement risk reduction strategies, to the operating microscope.”19 anesthesia: and reward successful interventions.29 The Authority’s resources for prevent- * Use the least invasive form of ing wrong-site surgery are available anesthesia appropriate to the case LIMITATIONS at http://patientsafetyauthority.org/ EducationalTools/PatientSafetyTools/ Relevant information is derived from * Reprinted with permission: The Betsy Lehman PWSS/Pages/home.aspx. These resources Center for Patient Safety and Medical Error the event type taxonomy and from include preoperative checklists such Reduction, 2016. http://www.betsylehmancen free-text narratives; categorization and as the Surgeon’s Office Checklist to terma.gov/initiatives/cataract-surgery.php Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 97 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S narrative detail are provided by the report comprehensive list of eye and cataract and family engagement with active partici- submitter. procedures, some may have been unknow- pation by staff in the implementation of Every effort was made to ensure that ingly excluded. the Universal Protocol and use of an oph- applicable procedure codes were identi- thalmology-specific perioperative checklist fied to present a comprehensive depiction CONCLUSION remain the recommended best practices of eye and cataract procedures in for preventing incorrect lens implantation, Events of incorrect IOL implants and Pennsylvania, including recognition that wrong-eye surgery, and wrong-site anesthe- wrong-site anesthesia eye injections are coding adjustments occurred during the sia eye injections. still reported through the Authority, even data collection period and impacted the though the incidence and level of harm The Authority welcomed the opportunity calculation of the number of cataract pro- are low. However, events have steadily to share data trends and information cedures before the third quarter of 2007. increased, indicating the opportunity to with The Center in Massachusetts, a col- As PHC4 explains, “Prior to Q3-2007, evaluate processes to prevent the potential league organization with complementary PHC4 outpatient data was reported with for these events. Individual facilities will patient safety goals. Willingness to contact a primary procedure and additional five find it beneficial to trend and analyze resources, share knowledge, and cooperate secondary procedure code fields; giving their own data and perioperative prac- with one another towards the common facilities the option of submitting ICD-9 tices. Information learned can be used to goal of improving cataract-related patient [inpatient] codes, CPT codes (HCPCS reduce safety hazards and implement risk- safety not only enhances interagency LEVEL I) and HCPCS LEVEL II codes. reduction strategies. expertise but furthers patient safety work Effective Q3-2007 facilities must report on a national level. The Center’s expert panel identified a either HCPCS LEVEL I OR HCPCS number of procedure-specific recommen- Acknowledgments LEVEL II codes. ICD-9 codes are no lon- dations to reduce the likelihood of error Theresa V. Arnold, DPM, Pennsylvania Patient ger valid for outpatient data.”5 Although Safety Authority, contributed to data analysis and in cataract surgery. Encouraging patient every effort was made to identify a inter-state agency collaboration for this article. NOTES 1. Simon JW, Ngo Y, Khan S, Strogatz D. healthgrades.com/explore/the-10-most- 12. 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Physician Quality Pages/office_tip.aspx Reporting System [online]. 2016 [cited 22. Self-assessment checklist for program 2016 Aug 24]. https://www.cms.gov/ elements associated with preventing Medicare/Quality-Initiatives-Patient- wrong-site surgery [online]. Pa Patient Saf Assessment-Instruments/PQRS/index. Advis 2010 [cited 2016 May 17]. http:// html?redirect=/pqri patientsafetyauthority.org/Educational- Tools/PatientSafetyTools/PWSS/Pages/ self_checklist.aspx Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 99 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 3—September 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. 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Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org. An Independent Agency of the Commonwealth of Pennsylvania ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 50 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. 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