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.
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.
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.