While VA Wrong Surgery Rates Drop, Close Calls Rise

The VA has since updated its procedure directives, "adding greater specificity such as the attending surgeon must personally confirm the position of the spine marker, there must be read-back on implants, and the operative site must be marked prior to anesthesia providers performing regional nerve blocks," they wrote.

"The rate of reported adverse events and harm decreased while close calls increased," they summarized. "Current plans and actions include sharing lessons learned from root cause analyses, policy changes" and additional MTT training.