Late Breaking News
Surgical Errors Dropped Significantly at VA; Safety Training Program Credited
WASHINGTON — Surgical errors have declined significantly at VA facilities nationwide, while the reporting of close calls has increased, according to a recent study. The study, conducted by VA researchers, credits agency-led quality improvement efforts with the decline in adverse events.
The same research group published a study in 2009 looking at incorrect surgical procedures in VA. That study, published in the Archives of Surgery in 2009, focused on wrong-site surgery — operations on the wrong body part, wrong patient or the wrong surgical procedure on a patient — in and out of the operating room (OR). Wrong-site surgery is the reviewable adverse surgical event most frequently reported to the Joint Commission, which accredits and certifies healthcare organizations across the U.S. Wrong-site surgery has been estimated to occur at a rate of between 0.09 and 4.5 cases per 10,000.
Researchers reviewed 212 adverse events and 130 close calls that occurred in VA facilities between 2001 and 2006. Of these, 108 adverse events (50.9%) occurredin an OR, and 104 (49.1%) occurred elsewhere. When examiningadverse events only, ophthalmology and invasive radiology werethe specialties associated with the most reports (45 each), whereas orthopedics was second to ophthalmology for numberof reported adverse events occurring in the OR. Pulmonary medicinecases (such as wrong-side thoracentesis) and wrong-site cases(such as wrong spinal level) were associated with the most harm.
The study concluded that the most common cause of these adverse events was poor communication. The researchers suggested that earlier communication among the surgical staff, and between the surgical staff and other providers dealing with the patients’ care, would help prevent surgical adverse events.
Better Communication, Fewer Problems
This most recent study is a follow-up to the 2009 findings and suggests that VA improvements, including those focused on better communication, have decreased surgical adverse events.