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Surgical safety woes linger, VHA researchers say


By Jean DerGurahian
Posted: November 17, 2009 - 11:00 am ET
Tags:

Incorrect surgical procedures continue to occur within the Veterans Health Administration, despite the use of interventions such as a “time out” to reduce safety events, according to researchers.

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Publishing in the Archives of Surgery, researchers at the VHA reviewed 342 events reported to the administration's National Center for Patient Safety database from Jan. 1, 2001 to June 30, 2006. Of those events, 212 were considered adverse events, in which a patient underwent an incorrect surgical procedure regardless of whether harm occurred. The other 130 were close calls, which occurred when a step toward an adverse event was taken without the patient being subjected to a surgical procedure.

Of the adverse events, about half occurred both in and out of the operating room. Most of all reported events happened because of communication problems or issues with the time-out process, according to the results. “Time-out procedures alone have not been enough to prevent incorrect surgical and invasive procedures,” the researchers wrote in their report.

Key areas in need of improvement include better communication to verify information with patients and ensuring proper equipment and supplies are prepared before the procedure begins, they said.

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