November 2018

VA Reports Downward Trend in Surgical Adverse Events #471178055

In an 8-year quality improvement follow-up study of reported surgical adverse events (AEs) at the US Veterans Health Administration (VHA), researchers found 277 AEs and 206 “close calls.” The data show a continuing of the downward trend from 1.74 to 0.47 AEs with harm for every 100,000 procedures, compared to the previous similar VHA studies (the periods 2001-2006 and 2006-2009). Incorrect procedure types were wrong patient, side, site (including wrong-level spine), procedure, or implant. Events included those in or out of the operating room (OR), adverse events or close calls, surgical specialty, and harm.

When in-OR events were examined by discipline as a rate, dentistry was first (1.54), followed by neurosurgery (1.53) and ophthalmology (1.06), reported as in-OR AEs for every 10,000 cases. Podiatrists were responsible for 2 AEs (1 wrong side, 1 wrong site) and ranked 14th on the list of 16 specialties; orthopedists, who ranked fourth on the list, were responsible for 19 AEs (5 wrong side, 4 wrong site, 3 wrong procedure, 6 wrong implant, 1 wrong level).

The overall VHA in-OR rate for adverse events during 2010 to 2017 was 0.53 per 10,000 procedures based on 3,234,514 in-OR procedures. The report identified issues in performing a comprehensive time-out (28.4%) as the most common root cause for AEs, citing  the time-out either was conducted incorrectly or was in some way incomplete.

Neily J, Soncrant C, Mills PD, et al. Assessment of incorrect surgical procedures within and outside the operating room: a follow-up study from US Veterans Health Administration medical centers. JAMA Netw Open. 2018;1(7):e185147.

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