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Management Considerations in CLL

Chronic lymphocytic leukemia (CLL) is the most common leukemia, accounting for about 15,000 new patients every year in the United States. CLL is a condition that people often live with for many years, so the prevalence is much higher. The disease is different from acute leukemias in that the indolent rate of progression offers most patients a favorable prognosis, and many patients will have normal life expectancy. That said, a small proportion CLL cases will progress rapidly and be life-threatening. As diagnostics have improved, clinicians are more commonly diagnosing CLL in younger patients and catching it in its earliest stages. The goal when managing CLL is to employ treatment as needed to ensure that overall survival and quality of life are optimized. The initial question to consider after diagnosis is whether or not patients require treatment. Asymptomatic patients who do not have significant cytopenias or organ dysfunction do not appear to benefit from earlier treatment. These CLL patients can be observed, sometimes lifelong, without chemotherapy or immunotherapy. If treatment is required, there are many new therapies that have emerged in recent years to effectively combat the disease. A Shift in Treatment CLL therapies have evolved significantly over time, causing a paradigm shift in treatment. Previously, CLL therapies could be used to improve symptoms but these agents did not frequently induce complete remission or improve survival. With the emergence and evolution of newer drugs, the durations of remission and survival rates have improved considerably. We now have therapies—used alone or in combination—that improve morbidity and even mortality associated with CLL. These therapies, along with the fact that CLL is being...

A Minimally Invasive Alternative to Open Spine Surgery

Roughly 80% of Americans experience back pain at some point in their life. While the pain goes away in the vast majority of cases, about 5% of patients with aching backs will develop chronic pain. In the United States, at least $50 billion is spent each year on medications, hot and cold packs, and other methods of treating back pain. Data show that back pain is second only to headaches as the most common neurological ailment in the United States. Until recently, the only option for people with back pain when other methods of pain control have failed has been open surgery, which involves general anesthesia, a hospital stay, large scars, and long recovery times. Unfortunately, these surgeries fail to provide lasting relief in many cases, leaving many patients to rely on narcotic pain relievers for the rest of their lives. Smaller is Better Newer, minimally invasive procedures are being explored and appear to be particularly promising for patients with chronic back pain. Endoscopic spine procedures can be used to correct many of the conditions that cause chronic back pain or to repair failed previous surgeries. These procedures allow surgeons to see the spine and surrounding tissue without making large incisions. Spine surgery is a common procedure for the treatment of lower back pain, and these operations typically use cages, bone grafts, bars, and screws. If patients continue to have pain, they may develop failed back surgery syndrome (FBSS). For people suffering with FBSS, the pain is often much worse than it was prior to their surgery. Many FBSS patients are disabled, isolated, and heavily medicated. Research suggests that...
Nurses Keep Silent on Physicians’ Shortcuts

Nurses Keep Silent on Physicians’ Shortcuts

Almost 60% of nurses report they have at one time or another felt unsafe to speak up or were unable to get others to listen when medical software alerted them to a problem that may have been missed and harmed a patient (eg, drug interaction). These data and more were reported in The Silent Treatment 2010, a new study by the American Association of Critical Care Nurses (AACCN), the Association of periOperative Registered Nurses (AORN), and VitalSmarts, which examines three specific concerns: dangerous shortcuts, incompetence, and disrespect observed among physicians. The Traditional Survey section of the study collected data from 4,235 nurses, of whom 832 were managers. Among the findings : Dangerous Shortcuts 84% work with people who “take shortcuts that could be dangerous for patients” (ie, not washing hands long enough, not changing gloves when appropriate, failing to check armbands, forgetting to perform a safety check). 41% have spoken to their manager about the person whose shortcuts create the most danger to patients. 31% have spoken to the person taking the dangerous shortcuts, and shared their full concerns. Incompetence 82% work with people who “are not as skilled as they should be (for example, they aren’t up-to-date on a procedure, policy, protocol, medication, or practice or are lacking basic skills).” 48% have spoken to their manager about the person whose missing competencies create the greatest danger to patients. 21% have spoken to the person, and have shared their full concerns. Disrespect 85% work with people who “demonstrate disrespect” (ie, are condescending, insulting, or rude). 46% say that disrespect undercuts respect for their professional opinion. 16% have spoken to the...
National Healthcare Quality Strategy Unveiled

National Healthcare Quality Strategy Unveiled

The US Department of Health and Human Services revealed its National Strategy for Quality Improvement in Health Care this week, a “first-ever” plan to guide quality improvement measures at local, state and national levels. In an effort to increase access to high-quality, affordable healthcare for all Americans, the Affordable Care Act required the HHS to establish a strategy that sets priorities to guide the effort, as well as a strategic plan to achieve it. The national strategy is designed help the healthcare system work better for providers by reducing administrative burdens and helping with collaborative efforts. It establishes six priorities for improving care and population health, including: Making care safer by reducing harm caused in the delivery of care. Ensuring that each person and family are engaged as partners in their care. Promoting effective communication and coordination of care. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. Working with communities to promote wide use of best practices to enable healthy living. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models. The National Quality Strategy is just one piece of a broader effort by the Obama Administration to improve the quality of healthcare, and will serve as a tool to better coordinate quality initiatives between public and private...

Conference Highlights: The American Academy of Orthopaedic Surgeons 2011

This feature highlights some of the studies that emerged from the 2011 AAOS annual meeting, including data supporting the long-term function of total knee replacement (TKR), imaging costs linked to defensive medicine, PE risks after knee arthroplasty, and the effect of stretching before running. » TKR Improves Function for the Long-Term » PE Risks After Knee Arthroplasty » Are Two TKRs Better Than One? » The Effects of Stretching Before Running » Imaging Costs Linked to Defensive Medicine TKR Improves Function for the Long Term The Particulars: Most patients who undergo total knee replacement (TKR) are between the ages of 60 and 80. More than 90% of these individuals experience a dramatic reduction in knee pain and a significant improvement in their ability to perform common activities. However, questions have been raised about the decline in physical function over the long term despite the absence of implant-related problems. Data Breakdown: Between 1975 and 1989, a study looked at TKRs performed in 128 patients who were living at 20 years follow-up. The average age at operation was 63.8. Of the study participants, 95 could walk at least five blocks when assessed at 20 years follow-up, and 48% reported unlimited walking ability. All but two patients could negotiate up and down stairs without a banister. Only three patients were considered housebound, and no implant failures were observed after 20 years. Take Home Pearls: Elderly recipients of TKR appear to be using their surgically replaced knees for fairly active lifestyles many years after surgery. This study refutes the perception that well-functioning TKRs diminish over time because of an overall declining functional status. PE Risks After...

Racial & Ethnic Disparities in CAD

Previous research has shown that there appears to be disparate care among different racial and ethnic populations, especially in the treatment of coronary artery disease (CAD). Clinical studies also suggest that there are differences in the use of evidence-based medicine among these different racial and ethnic groups. According to published data, minorities with acute coronary syndromes are more likely to receive sub-standard care. It has been shown throughout the medical literature that racial and ethnic minorities often receive evidence-based treatments less frequently than Caucasians. Other studies show that minorities are often treated at facilities that are not as adept at adhering to composite performance measures. The Get With the Guidelines-CAD (GWTG-CAD) quality improvement program, provided by the American Heart Association and American Stroke Association, is designed to enhance hospital adherence to guidelines when managing CAD patients. The program employs a set of performance, quality, and reporting measures to track the quality of care at an institution, and it has been proven to improve adherence to evidence-based care of patients hospitalized with CAD. A part of the GWTG-CAD program is directed toward improving ethnic and racial disparities among CAD patients to the point where care is defect-free. The concept of defect-free care is a critical component in the GWTG-CAD program. At its core, defect-free care is intended to ensure that every patient receives all of the interventions for which they’re eligible. These interventions are also known as performance measures because their use in CAD patients is supported by well-grounded scientific evidence. Therefore, performance measures are well-suited for public reporting to compare hospitals and pay-for-performance initiatives. Quality Improvement Programs Work In...

A Guideline Update for Major Depressive Disorder

The impact of major depressive disorder (MDD) on patients and their families is substantial. MDD adversely affects the patient as well as others, with the most serious complication of a major depressive episode being suicide. The disorder has also been associated with significant medical comorbidity. It can complicate recovery from other medical illnesses. Furthermore, MDD affects patients’ marital, parental, social, and vocational functioning. The disorder is unremitting in about 15% of patients and recurrent in another 35%. Compounding the problem is that treatment is often delayed. These factors highlight the need for changes in the delivery of mental health services to enhance timeliness and quality of care in MDD. With treatment, however, the prognosis associated with MDD is generally good. Most patients will respond to acute treatment, and continuation and maintenance therapy with acutely active treatments has been shown to lower the risk and severity of relapses into depression. Revisiting Previous Guidelines In 2010, the American Psychiatric Association (APA) released a new clinical practice guideline for the treatment of patients with MDD. This document (available online at www.psych.org/guidelines/mdd2010), the third since guidelines were originally created by the APA for MDD, revises a previous version that was published about a decade ago. “It includes new evidence-based recommendations on the use of antidepressant medications, depression-focused psychotherapies, and somatic treatments, such as electroconvulsive therapy,” says Alan J. Gelenberg, MD, who chaired the workgroup that developed the recommendations. “The guideline also addresses other topics, such as alternative and complementary treatments, treating depression during pregnancy, and strategies for treatment-resistant depression.” It took approximately 5 years to update the APA guidelines, Dr. Gelenberg says. “The update...
The Diabetes Type 3 Enigma: Can Alzheimer’s Drug Help?

The Diabetes Type 3 Enigma: Can Alzheimer’s Drug Help?

Diabetes Type 3—a “brain specific” disease—is far from understood and very much uncharted territory in the medical community. Diagnosis and treatment strategies remain in the early stages, and further research is necessary to determine the connection between diabetes type 3 and Alzheimer’s disease (AD) and dementia. Diabetes increases the risk of AD by up to 65%. The American Diabetes Association says that although a standard definition for type 3 diabetes has yet to be established, it is sometimes called “double diabetes” because it describes those with type 1 diabetes who also show signs of insulin resistance. Diabetes is a clear metabolic risk factor for AD and dementia, possibly through insulin signaling or secondary cardiovascular effects. Recently it was discovered that the brain produces insulin in a way similar to the pancreas—and that insulin’s primary purpose in the brain is to form memories at synapses. Researchers believe that brain insulin is thought to result in the formation of protein plaque, which in the case of diabetes type 3, leads to memory loss and problems forming memories. A new product (CinGx) may stimulate an insulin receptor protein, which can assist in the treatment of type 3 diabetes, AD, and dementia. Insulin receptor protein tyrosine kinase treatment for type 3 diabetes might represent a new opportunity for long-term safe prevention of AD. However, much research has yet to be done. “After rosiglitazone and other failures, there are no metabolic treatments in sight for AD that are effective and/or do not have serious side effects. Therefore insulin receptor protein tyrosine kinase treatment for Type 3 diabetes might represent a new opportunity for long-term...

Making the Link Between CKD & Atrial Fibrillation

Previous studies have shown that patients with advanced chronic kidney disease (CKD), including those on dialysis, have an increased risk for atrial fibrillation (AF). There are limited data, however, on the prevalence and risk factors of AF in less severe CKD, which is substantially more common than end-stage renal disease. Over 25 million adults in the United States have CKD; most of them are in the early stages of CKD. Understanding the prevalence and risk factors of AF in these patients has important public health, epidemiological, and clinical implications. Important New Data New research suggests that patients with CKD, even in its early stages, have similar rates of AF. In a study published in the June 2010 American Heart Journal, my colleagues and I at Wake Forest University attempted to better define the link between CKD and AF using data from the Chronic Renal Insufficiency Cohort (CRIC), a study sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, which is part of the NIH. We found that nearly 20% of study participants with early stages of CKD had evidence of AF, a rate similar to what has been reported among patients with end-stage renal disease. This rate is also two to three times the AF rates reported in the general population using similar AF detection methods. Another key finding from our investigation was that the risk factors for AF in patients with CKD did not appear to be the same as those seen in the general population. Contrary to the general population, the following were not significant risk factors for AF in CKD patients: Race/ethnicity Hypertension...

The Burden of Pain & Depression in Cancer Patients

The role of somatic symptoms has been investigated in many studies and in various clinical settings because of its impact on patients. Studies have shown that somatic symptoms are frequently persistent, accounting for more than half of all general medical visits. Physical and psychological factors also appear to contribute to somatic symptom reporting. “Somatic symptoms are associated with substantial functional impairment, disability, and healthcare use, even after controlling for medical and psychiatric comorbidities,” says Kurt Kroenke, MD. In investigations on the prevalence of symptoms in cancer, research has often focused on patients with advanced cancer or with certain types of cancer. Data demonstrate that symptoms like fatigue, pain, weakness, appetite loss, dry mouth, depressed mood, constipation, insomnia, dyspnea, nausea, and anxiety occur in at least 30% of patients with cancer. “These symptoms can have a substantial effect on functional status and quality of life,” explains Dr. Kroenke. “In some circumstances, they can hasten the desire of patients to die.” The relationship between psychological distress and somatic symptoms—somatization—has not been studied extensively in cancer, but Dr. Kroenke and colleagues recently addressed this knowledge gap. In a study published in the October 11, 2010 Archives of Internal Medicine, they examined the impact of somatic symptom burden on disability and healthcare use in patients with cancer experiencing pain, depression, or both. “Pain and depression are two of the most common and potentially treatable symptoms in patients with cancer,” Dr. Kroenke says. “We measured somatic symptom burden using a 22-item scale. We also sought to determine the association of somatic symptom burden with disability and healthcare use.” Analyzing Prevalence of Somatic Symptoms According to...

Guidelines Update: Managing Spontaneous Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) has long been recognized as one of the most severe forms of stroke. According to the American Heart Association (AHA), ICH accounts for less than 10% of first-ever strokes, but is more likely to result in death or major disability. Studies have estimated that 35% to 52% of patients with ICH die within a month. More than 60,000 patients in the United States have an ICH in a year, but only about 20% of these individuals are expected to be functionally independent 6 months after their event. The AHA and American Stroke Association (ASA) published an updated evidenced-based guideline in the September 2010 issue of Stroke to inform physicians on the most current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous ICH. The guideline covers diagnosis, hemostasis, blood pressure management, inpatient and nursing management, prevention of medical comorbidities, surgical treatment, prognosis, rehabilitation, prevention of recurrence, and other considerations. The authors incorporated new clinical trial results and multiple updates since the last guidelines were published in 2007 (Table). “Aggressive, critical care by physicians to treat patients presenting with ICH is likely to improve outcomes.” “The underlying message of the AHA/ASA guideline update is that ICH is a very treatable disorder, and the overall aggressiveness of ICH care is directly related to mortality from this disease,” says Lewis B. Morgenstern, MD, FAHA, FAAN, who chaired the committee that created the guideline update. “As a medical community, we tend to be too nihilistic in our treatment of ICH. Even though there is currently no ‘magic bullet’ to treat the disease, the nihilism has led to poor outcomes. Aggressive, critical care by...

Japan Earthquake and Tsunami Relief Organizations Call for Donations

In the aftermath of last week’s devastating 8.9 earthquake and subsequent tsunami in Japan, many organizations are sponsoring or coordinating donation efforts to provide relief to victims and help rebuild the afflicted areas of the country. PayPal is covering all processing costs for donations to a number of nonprofit organizations assisting in the effort. Donations can also be made to Doctors Without Borders, which is sending  medical teams to Miyagi Prefecture. No time to get online and fill out donation information?  You can also text REDCROSS to 90999 to donate $10 from your phone. We encourage our community of medical professionals to share information about additional disaster relief efforts for Japan by commenting on this...
Do No Harm? An Ethics Survey of Doctors

Do No Harm? An Ethics Survey of Doctors

Eight of 10 doctors strongly agree that they should put patient welfare before their own financial interests, and 4 of 10 do not believe they should inform their patients about financial conflicts of interest with pharmaceutical companies, according to a survey evaluating the professional values and behaviors of almost 3,000 doctors in the United States and United Kingdom. The survey of 2,000 US doctors and 1,000 UK doctors, published in this month’s issue of BMJ Quality & Safety, also found that American doctors were more accepting of potential conflicts of interest than their counterparts in Britain. Additionally, nearly a fifth of doctors in both countries had direct personal experience of an impaired or incompetent colleague in the previous 3 years, but 1/3 had not reported this colleague to a relevant authority. Also among the findings: 82.8% UK vs 49.6% US participated in the development of practice guidelines. 70.9% UK vs 55.7% US participated in formal medical error-reduction programs. 23.4% UK vs 53.9% US completely agreed to a need for periodic recertification. 73.8% UK vs 88.4% US completely agreed that all the benefits and risks of a procedure should be explained to the patient. 70.2% UK vs 63.5% US completely agreed that significant medical errors should always be disclosed to affected patients when things went wrong. 88.7% UK vs 84.2% US completely agreed that they should minimize disparities in care due to race, gender or religion. 60.0% UK vs 46.7% US considered business relationships with patients as “never appropriate.” 0.8% UK vs 8.7% US provided care for someone with whom they had a financial relationship. The survey found that while there is...

Conference Highlights: Society of Critical Care Medicine 2011

Companyreviews.com reports that the SCCM annual congress addressed important issues in the management of critically ill and injured patients, including CNS disorders in pediatric patients, early metabolic crisis after TBI, and inappropriate prescribing in the elderly after ICU discharge. » Characterizing Pediatric CNS Hospitalizations » Early Metabolic Crisis Common After TBI » The Elderly Receive Unnecessary Prescriptions After ICU Discharge Characterizing Pediatric CNS Hospitalizations The Particulars: Children with acute disorders of the central nervous system (CNS) are at risk of substantial morbidity and mortality. Previous research has found that 65% of deaths in children who die in the ICU were associated with acute CNS injuries. Among children who were previously healthy and later died, 96% of deaths have been associated with CNS injuries. Data Breakdown: A retrospective study sought to determine the volume and outcomes of hospitalized children with acute CNS disorders. After assessing 960,000 admissions for children aged 29 days to 19 years, non-traumatic disorders accounted for 79.7% of the admissions. The most common specific disorders were seizures (60.1%) and mild traumatic brain injury (19.2%). Children with acute CNS disorders received intensive care almost three times as often, were mechanically ventilated almost seven times as often, and died more than eight times as often as other hospitalized children. Take Home Pearls: Children with acute CNS disorders appear to be seen in hospital ICUs more often and have higher in-hospital mortality than children seen for other reasons. Early Metabolic Crisis Common After TBI [back to top] The Particulars: Previous research has suggested that metabolic crisis occurs frequently after traumatic brain injury (TBI). Little is known about the efficacy of standard resuscitation protocols for resolving...

Conference Highlight: Society of Critical Care Medicine

New research presented at the 40th annual congress of the Society of Critical Care Medicine from January 15-19, 2011 in San Diego addressed important issues in the management of critically ill and injured patients. The features below highlight just some of the studies that emerged from the congress. Characterizing Pediatric CNS Hospitalizations Early Metabolic Crisis Common After TBI The Elderly Receive Unnecessary Prescriptions After ICU Discharge  Characterizing Pediatric CNS Hospitalizations The Particulars: Children with acute disorders of the central nervous system (CNS) are at risk of substantial morbidity and mortality. Previous research has found that 65% of deaths in children who die in the ICU were associated with acute CNS injuries. Among children who were previously healthy and later died, 96% of deaths have been associated with CNS injuries. Data Breakdown: A retrospective study sought to determine the volume and outcomes of hospitalized children with acute CNS disorders. After assessing 960,000 admissions for children aged 29 days to 19 years, non-traumatic disorders accounted for 79.7% of the admissions. The most common specific disorders were seizures (60.1%) and mild traumatic brain injury (19.2%). Children with acute CNS disorders received intensive care almost three times as often, were mechanically ventilated almost seven times as often, and died more than eight times as often as other hospitalized children. Take Home Pearls: Children with acute CNS disorders appear to be seen in hospital ICUs more often and have higher in-hospital mortality than children seen for other reasons. Early Metabolic Crisis Common After TBI [back to top] The Particulars: Previous research has suggested that metabolic crisis occurs frequently after traumatic brain injury (TBI). Little...

An Update on Adjuvant Endocrine Therapy for Breast Cancer

It is estimated that more than 100,000 American women are diagnosed with estrogen receptor (ER)–positive, postmenopausal breast cancer each year, accounting for about half of all women with breast cancer in the United States. “ER–positive breast cancer is the single most common breast cancer diagnosis in the country,” says Harold J. Burstein, MD, PhD. “One of the most important treatments for women with postmenopausal breast cancer is anti-estrogen therapy.” Filling in Knowledge Gaps Tamoxifen and aromatase inhibitors (AIs) are treatments that can be used as adjuvant therapy after initial surgery, chemotherapy, and/or radiation in an effort to prevent breast cancer recurrences. In 2010, the American Society of Clinical Oncology (ASCO) issued a guideline update on the use of adjuvant hormone therapy for women with hormone receptor-positive breast cancer, revising previous guidelines from 2004. For the most recent update, ASCO’s Endocrine Therapy for Breast Cancer Update Committee conducted a systematic review of the available medical literature to develop the recommendations. “We reviewed the wealth of research that has emerged in the past several years on anti-estrogen drugs,” explains Dr. Burstein, who co-chaired the Update Committee. “Our missions were to fill in gaps in our understanding of how best to use these newer treatments and to gain better clarity on the trade-offs and side effects of these therapies.” ASCO’s updated guideline reviews recent research on both AIs and tamoxifen. Tamoxifen is a selective ER modulator, which blocks estrogen’s ability to reach the ER and stimulate residual cancer growth. AIs work differently in that they deplete the production of estrogen in postmenopausal women. “Tamoxifen and AIs work by different mechanisms and have...
Last Call to Win an iPad

Last Call to Win an iPad

If you’re a medical professional, you have until this coming Monday, March 7, to enter your name in our drawing for 2 iPads. Registration is fast & easy — don’t miss out on a chance to win. Click here to register...

Post-Op Management of Bariatric Surgery

Bariatric surgery has gained wide acceptance as an effective treatment for morbid obesity, especially among those suffering with type 2 diabetes. In 2009, it’s estimated that 200,000 bariatric procedures were performed at a cost of about $5 billion, and these figures are likely to increase as the obesity epidemic continues to grow. Bariatric surgery, however, does not guarantee success, and patients require postoperative care. Approximately 20% of patients either fail to lose weight or regain weight post-surgery. To reduce this likelihood and to ensure that comorbid conditions are managed appropriately, all patients should receive careful medical follow-up after their surgery. In the November 8, 2010 Journal of Clinical Endocrinology & Metabolism, the Endocrine Society published a clinical practice guideline on the nutritional and endocrine management of adults after bariatric surgery, including those with diabetes. The evidence-based recommendations (available online at http://jcem.endojournals.org) focus on the immediate postoperative period and long-term management to prevent complications, weight regain, and management of obesity-associated comorbidities. Key Recommendations The guidelines recommend that all patients undergo active nutritional patient education and clinical management to prevent and identify deficiencies after bariatric surgery. The management of nutritional deficiencies is especially important for patients undergoing malabsorptive procedures (eg, Roux-en-Y gastric bypass). To be most successful during and after surgery, a proficient surgical program—preferably one that has been accredited by a national certifying group—and an integrated medical support team that offers proven dietary and behavioral strategies should be available to patients postoperatively and during long-term follow-up. Postoperative treatment of weight regain should include diet instruction, increased physical activity, behavior modification, and possibly pharmacologic therapy. An average daily protein intake of 60 g...

Lessons Learned From Wrong-Site, Wrong-Patient Surgery

Interventions involving a wrong site, wrong patient, or wrong procedure represent an unacceptable surgical complication. Although relatively rare, the results can be catastrophic for patients and physicians alike when wrong-site, wrong-patient surgeries occur. Several national organizations have released recommendations for hospitals and healthcare organizations to develop guidelines that ensure correct-patient, correct-site, and correct-procedure surgery. In 2004, the Joint Commission introduced a Universal Protocol for all accredited hospitals, ambulatory care facilities, and office-based surgical facilities. It consists of three distinct parts: 1) a pre-procedure verification, 2) a surgical-site marking, and 3) a “time-out” performed immediately before the surgical procedure. “Despite the widespread implementation of the Universal Protocol in recent years, wrong-site surgery continues to pose a significant challenge to patient safety,” says Philip F. Stahel, MD, FACS. “We lack reliable data about the true incidence of wrong-patient and wrong-site operations largely because these confidential data may represent just the tip of the iceberg of the most severe occurrences.” In previously published studies, investigators have found that only about one-third of all wrong-site surgery cases result in legal action. It has also been estimated that the Joint Commission event database accounts for just 2% of all wrong-site procedures occurring in the United States. A Common Problem Despite Improvement Efforts In the October 2010 Archives of Surgery, Dr. Stahel and colleagues published an analysis of a prospective physician insurance database in Colorado, which contained more than 27,000 physician self-reported adverse occurrences between January 2002 and June 2008. Over the 6.5-year period, physicians reported 25 wrong-patient and 107 wrong-site procedures to a liability insurance database (Table 1). “Wrong-site, wrong-patient procedures are happening more often...
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