Veteranclaims’s Blog

November 16, 2009

VA Surgical Mistakes Outlined in Report

Medical errors are a fact of life, even though we wish they were not.
I think the quote about accuracy in reporting these errors is one that needs to be taken into account.
The concern about the nonreporting of adverse surgical events was echoed in an accompanying editorial by George C. Velmahos, MD, PhD, of Massachusetts General Hospital in Boston.

Full Article at: Surgical Mistakes Continue Despite VA Initiative
By Nancy Walsh,
Published: November 16, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

“Despite a concerted effort to reduce them, surgical mistakes, particularly errors in communication, continue to occur in the operating room and elsewhere in hospitals, a Veterans Health Administration study found.

A total of 342 events were reported to a national database between January 2001 and June 2006, 212 of which were actual adverse events and 130 of which were close calls, according to Julia Neily, RN, of the Department of Veterans Affairs in White River Junction, Vt.

A total of 108 (50.9%) of the adverse events occurred in the operating room and 104 (49.1%) occurred in other locations such as procedure rooms and radiology suites, the researchers reported in the November Archives of Surgery.

“Incorrect surgical procedures can be devastating,” and an estimated five to ten of these occur daily in the U.S., the researchers wrote.

In January 2003 the Veterans Health Administration began implementing protocols to ensure correct surgical procedures in its 153 major centers. It focused first on operating room errors and then expanded the effort to nonoperating room events in 2004 in a directive known as the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.

To evaluate the initiative, Neily and colleagues searched the administration’s patient safety database for events that occurred during a 5.5 year period, and found that ophthalmology and invasive radiology had the most reports, with 45 each (21.2%).

The most common type of event involved a communication error (21%), such as mistakes in informed consent or in the dissemination of important information among staff.

Another common type of event related to “time-out” errors (17.6%), which occur when the surgical team is supposed to verify the correct patient, procedure, site, and implants (if applicable) before proceeding with the operation.

The researchers also calculated adverse event rates, reporting that there were 1.8 adverse events per 10,000 cases in ophthalmology and 1.2 per 10,000 cases in orthopedics. In both specialties the most common error was placement of the wrong implant (48.9% and 46.2%, respectively).”

“The researchers emphasized the need for communicating more clearly and earlier when preparing for surgical and invasive procedures, and suggested incorporating the patient into the preoperative briefing to aid in communication.

“We need to work proactively to prevent incorrect surgical procedures; waiting until moments before “take-off” (such as during the final time-out) may, at times, be too late to correct the problem,” they wrote.”

“The concern about the nonreporting of adverse surgical events was echoed in an accompanying editorial by George C. Velmahos, MD, PhD, of Massachusetts General Hospital in Boston.

“We . . . rely in great part on honesty and personal values for the candid reporting of many adverse events,” he wrote.

“It is hard to imagine that errors never occur in some specialties and routinely happen in others. It is possible that honesty is exposed and penalized; an attitude of convenient forgetfulness is not,” Velmahos wrote.

For example, the frequency of reported events in ophthalmology in this study may reflect a quality assurance-attentive department head.

Standardized systems that can reliably capture all adverse events are needed to minimize the need to rely on human nature, which “we would all agree . . . is rather imperfect,” he cautioned.”

This work was supported by the Department of Veterans Affairs.

Primary source: Archives of Surgery
Source reference:

Neily J, et al “Incorrect surgical procedures within and outside of the operating room” Arch Surg 2009; 144: 1028-34

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