Surgical Mistakes Continue Despite VA Initiative

By Nancy Walsh, Contributing Writer, MedPage Today
Published: November 16, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Despite a concerted effort to reduce them, surgical mistakes, particularly errors in communication, continue to occur in the operating room and elsewhere in hospitals, a Veterans Health Administration study found. A total of 342 events were reported to a national database between January 2001 and June 2006, 212 of which were actual adverse events and 130 of which were close calls, according to Julia Neily, RN, of the Department of Veterans Affairs in White River Junction, Vt. A total of 108 (50.9%) of the adverse events occurred in the operating room and 104 (49.1%) occurred in other locations such as procedure rooms and radiology suites, the researchers reported in the November Archives of Surgery. “Incorrect surgical procedures can be devastating,” and an estimated five to ten of these occur daily in the U.S., the researchers wrote. In January 2003 the Veterans Health Administration began implementing protocols to ensure correct surgical procedures in its 153 major centers. It focused first on operating room errors and then expanded the effort to nonoperating room events in 2004 in a directive known as the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. To evaluate the initiative, Neily and colleagues searched the administration’s patient safety database for events that occurred during a 5.5 year period, and found that ophthalmology and invasive radiology had the most reports, with 45 each (21.2%). The most common type of event involved a communication error (21%), such as mistakes in informed consent or in the dissemination of important information among staff.


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