If you're opening a new surgical facility, you can expect a longer-than-usual wait for a visit from your state Medicare surveyor. Citing an increase in the number of new providers applying to participate in Medicare as well as limited resources, CMS has directed state surveyors to give new Medicare applicants the lowest priority, according to a memorandum sent to state survey agency directors.

CMS says it hopes that new providers won't wait for state survey visits and will instead decide to pay private accreditation organizations such as the Joint Commission, AAAHC or AAAASF to provide Medicare deemed status through accreditation surveys.

"Due to severe resource limits for Medicare survey and certification functions, in most states few providers that have the option of deemed accreditation will be surveyed by CMS or the state," says the memo. "While the applicant will pay a fee to the [accrediting organization] for the initial survey, applicants may conclude that the benefits outweigh the expense, particularly the expense of time waiting for a no-cost survey."

Since 2002, the number of Medicare-participating ambulatory surgical centers has increased by 38.4 percent, says CMS.

"In the past, many providers have preferred to have state agencies conduct the initial Medicare certification survey because the state surveyors do not charge for the surveys," says healthcare lawyer Nate Gilmer of Waller Lansden Dortch & Davis in Nashville, Tenn. "CMS's new survey directive will undoubtedly change this practice, as few new providers will be willing to wait for the state surveyor to make it to the end of their priority lists."

Mr. Gilmer adds that by forcing providers to use third-party accreditation, CMS is shifting the financial burden of Medicare's initial survey to providers. He also notes that some providers have complained that accreditation standards are needlessly technical, subject to frequent change and not well suited to their organizations. "Perhaps most significantly, the accreditation process can be time consuming," says Mr. Gilmer. "Providers will now have to build the accreditation process into their timelines for the creation of new facilities."

Wrong-site, wrong-patient and wrong-procedure incidents occur only 69 times out of 1 million ophthalmic surgery procedures. But most of the ones that do occur could have been prevented if the Joint Commission's Universal Protocol had been followed, according to a study published in the November issue of the Archives of Ophthalmology.

Researchers looked at 106 eye surgery errors that had occurred in New York state between 1982 and 2005. Using the wrong lens implant was the most common error, occurring in 67 of the cases. "All the lenses look the same and the patient can't help you," says lead author John W. Simon, MD, of the Lions Eye Institute at Albany Medical College.

Wrong-eye operations occurred in 15 of the cases, followed by 14 errors involving the administration of anesthesia to the wrong eye. Wrong-patient and wrong-procedure errors were cited in eight cases and a wrong corneal transplant in two.

The authors note that, all told, 90 of the cases - or 85 percent - could have been prevented through the conscientious use of the Universal Protocol. Although that rule was published in 2004, clinicians still have to concentrate on putting it to use, Dr. Simon says, noting that surgeons, staff and administrators should look to the airline industry. "It's just like when a pilot takes a plane to the runway. You need to have checklists," he says.

Not all the errors were rooted in the OR, though, says Dr. Simon, who explains that many occurred farther upstream in the process. As a result, a facility's administrators and clerical staff should be included in efforts to prevent errors, says Dr. Simon.

Finally, punishing providers who make mistakes is not going to prevent mistakes from happening. Humiliation and discipline will perpetuate a culture of secrecy when it comes to reporting errors, says Dr. Simon. "We need to get beyond the culture of blame, shame and train," he adds.

The prolonged use of morphine can quickly cause an unwanted tolerance to the medication's pain-relieving effects, but researchers at St. Louis University say they have discovered ways to prevent the diminishing efficacy of the drug's analgesic properties.

According to their findings, published in the November issue of The Journal of Clinical Investigation, blocking the development of the oxidant peroxynitrite in the spinal cord reduces a patient's tolerance to repeated doses of morphine.

Daniela Salvemini, PhD, professor of internal medicine in the division of pulmonary, critical care and sleep medicine at the St. Louis University School of Medicine, led a team of researchers who found that repeated doses of morphine caused peroxynitrite to develop in the spinal cords of mice, which caused inflammation and damaged proteins and DNA in the cord.

The St. Louis researchers believe the simultaneous administration of a drug that prevents peroxynitrite from working will let patients take morphine without developing a tolerance. That, says Dr. Salvemini, will eliminate the strong possibility of a patient forming a morphine addiction and the complications associated with increased dosing of the drug: oversedation, reduced physical activity, respiratory problems and constipation.

"We believe these findings represent a major breakthrough in understanding how tolerance to the pain-relieving action of morphine and other opiate medications develops - and how it can be prevented from happening in the first place," says Dr. Salvemini, adding that her research could help maintain the pain-relieving effects of opiates while reducing their negative side effects.