• Julia Neily, Peter D Mills, Noel Eldridge, Brian T Carney, Debora Pfeffer, James R Turner, Yinong Young-Xu, William Gunnar, and James P Bagian.
• Veterans Health Administration, White River Junction, VT 05009, USA. julia.neily@va.gov
• Arch Surg. 2011 Nov 1;146(11):1235-9.

ObjectiveTo describe incorrect surgical procedures reported from mid-2006 to 2009 from Veterans Health Administration medical centers and build on previously reported events from 2001 to mid-2006.DesignRetrospective database review.SettingVeterans Health Administration medical centers.InterventionsThe Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety.Main Outcome MeasuresThe categories were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm.ResultsOur review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P = .02). Reported close calls increased from 1.97 to 3.24 per month (P ≤ .001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%).ConclusionsThe rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed.

25 keywords...

hide…