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While VA Wrong Surgery Rates Drop, Close Calls Rise

Cheryl Clark, for HealthLeaders Media, July 21, 2011

The rate of serious adverse events involving wrong surgeries in the Veteran's Health Administration's medical centers has been dropping, but failure to standardize critical clinical processes is still the biggest reason for their occurrence and close calls are increasing.

That's the conclusion of an updated review, which tracked numbers, rates, specialties and causes of incorrect surgical procedures and near misses at VA hospitals between 2001 and 2009. It was published online in this week's Archives of Surgery.

Rates of incorrect surgeries per 10,000 procedures went from 1.74 and 2.29 in 2001 and 2002 to .53 and .51 in 2008 and 2009, and with the exception of 2006, when rates were 1.65, remained below 1.09 since 2003, they wrote.

Over a 66-month period between 2001 and mid-2006, there were 212 adverse events, or 3.21 per month but from mid 2006 to 2009, a 42-month period, there were 101, or 2.4 per month. Reported close calls increased from 130 or 1.97 per month to 136, or 3.24 per month.

The report identified wrong side and wrong patient surgeries as the most common type of adverse surgical event, followed by wrong site, wrong implant, and wrong procedure.

In addition to lack of standardized processes, other influential root causes included human to machine interface, look-alike packaging of different implant components, time pressures, distraction, environmental problems or fatigue.

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