sutures newsletter


Leon Morgenstern, MD: 1919-2012

Leon Morgenstern, MD, a beloved colleague and the founding director of surgery for Cedars-Sinai Medical Center, died Dec. 23 at his home in Malibu at age 93. A surgeon, scholar, humanist, medical researcher and prolific author, he remained active after his retirement and was working in his Cedars-Sinai office as recently as Dec. 21.

Cedars-Sinai is planning a memorial in his honor.

Mark your calendar

Grand rounds

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Surgery scheduling

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Reversing the trend in APLs

"Accidental Puncture and Laceration" is a patient safety indicator developed by the Agency for Healthcare Research and Quality that is reported on the Centers for Medicare & Medicaid Services website to report adverse events for individual hospitals. The indicator rate is calculated from the hospital's coding of diagnoses and conditions that is based on physician documentation.

Historically, Cedars-Sinai's Accidental Puncture and Laceration (APL) rates have been very high compared to other hospitals; upon review, it appears our rates are inflated because our Health Information Management coders are using cues from the operative note, like "injury" or "repair," to assign diagnoses for accidental punctures or lacerations when, in some cases, the involvement of other organs was actually reasonably necessary to accomplish the surgery.

For example, a loop of ileum, completely adherent to the uterus from endometriosis, would be entered while attempting to free it. The gynecologists would dictate that the bowel was inadvertently entered, and it would be reported as an APL. With education of our Ob/Gyn colleagues to document that this was unavoidable and intentional as part of the procedure, the rate has dropped dramatically and more clearly reflects true APLs. As surgeons, we can be more accurate in our dictations. If there are extensive severe adhesions, document that. Think about these two statements, both of the same operation:

"The colonic disease process involved the ureter, which required segmental resection and primary anastomosis over a double J stent."

"In mobilizing the diseased colon, the ureter was also divided, which we fixed."

The second would be coded as an APL, the first would not.

When dictating operative reports, think about how to make it clear to the reader (and coder) what occurred.

Click the link below for a graphic illustrating Cedars-Sinai's rates.

APL Trend Graphic (PDF)