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While VA Wrong Surgery Rates Drop, Close Calls Rise

Cheryl Clark, for HealthLeaders Media, July 21, 2011

Julia Neily, of the VHA in White River Junction, VT, and colleagues prepared their paper based on their review of the VA National Center for Patient Safety database. They described many possible reasons for the decline, including an increased focus on OR safety, implementation of the VA's MTT (Medical Team Training) program, and improved team communication in the OR.

But errors and potential errors remain, she wrote. Neily's group said that the top three specialties reporting adverse events in and out of the operating room were ophthalmology, invasive radiology and orthopedic, but neurosurgery – specifically spine procedures – had the highest rates of reported adverse events, followed by ophthalmology.

Ophthalmology, the researchers said, "continued to have challenges with wrong implants. In some situations, teams had the correct implant in the room before the procedure but also had several others lenses in the room that contributed to the risk for error.  In other situations, they pulled the lens based on the incorrect patient's data so even though they verified what they thought was the correct lens during the time-out, the implant was pulled based on incorrect data."

For orthopedics, there was improvement. Adverse events related to implants went from 46% in the span between 2001 and 2006 to 23% between 2006 and 2009.

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