In 2002, prompted in part by the release of the 1999 Institute of Medicine report titled “To Err is Human: Building a Safer Health System,” the National Quality Forum (NQF) created a list of 27 Never Events which was expanded to 28 events in 2006. The NQF defines Never Events as errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients.  Included in the list of Never Events as a Surgical Event, is surgery performed on the wrong patient.

Medicare beneficiaries experience serious injury and/or death due to surgeries performed on the wrong patient and additional costs are incurred by Medicare in order to correct adverse outcomes resulting from these errors. In order to address and reduce the occurrence of these surgeries CMS has decided to internally generate a national coverage analysis (NCA) to develop a national coverage determination (NCD) regarding coverage and payment for surgeries performed on the wrong patient.