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Key Points Question Are reported rates of incorrect surgery changing in the US Veterans Health Administration (VHA)? Findings This quality improvement study found that VHA-reported surgical adverse events have continued to trend downward from 1.74 to 0.47 per 100 000 procedures between 2000 and 2017. In this context, dentistry, neurosurgery, and ophthalmology remain a challenge. Meaning The VHA is holding the gains with preventing incorrect surgical procedures while continuing to work in selected areas of continued challenge.

Study Design: Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA). Objective: To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue. Summary of Background Data: Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients. Materials and Methods: We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated. Results: There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues. Conclusions: Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.

This quality improvement project describes 22 OR patient falls reported in the Veterans Health Administration between January 2010 and February 2016. Most (n = 15; 68%) involved patient falls from the OR bed. Other patient falls (n = 6; 27%) occurred when the patient was transferred to or from the OR bed, and one fall (5%) occurred at another time. Root causes of the falls included tilting of the OR bed, issues with safety restraints, malfunctioning OR bed or gurney locks, inadequate patient sedation, and poor communication among team members. One fall (5%) resulted in a major injury, four falls (18%) resulted in minor injuries, six falls resulted in no injury, and 11 falls (50%) had no reported outcome. Falls in the OR, although rare, can be injurious. We drafted recommendations based on the root causes that include specific guidance on communication, teamwork, best practices, restraints and equipment, and training.

Objectives The aim of the study was to compare retained surgical item (RSI) rates for 137 Veterans Health Administration Surgery Programs with and without surgical count technology and the root cause analysis (RCA) for soft good RSI events between October 1, 2009 and December 31, 2016. A 2017 survey identified 46 programs to have independently acquired surgical count technology. Methods Retained surgical item rates were calculated by the sum of events (sharp, soft good, instrument) divided by the total procedures performed. The RCAs for RSI events were analyzed using codebooks for procedure type/location and root cause characterization. Results One hundred twenty-four RSI events occurred in 2,964,472 procedures for an overall RSI rate of 1/23,908 procedures. The RSI rates for 46 programs with surgical count technology were significantly higher in comparison with 91 programs without a surgical count technology system (1/18,221 versus 1/30,593, P = 0.0026). The RSI rates before and after acquiring the surgical count technology were not significantly different (1/17,508 versus 1/18,673, P = 0.8015). Root cause analyses for 42 soft good RSI events identified multiple associated disciplines (general surgery 26, urology 5, cardiac 4, neurosurgery 3, vascular 2, thoracic 1, gynecology 1) and locations (abdomen 26, thorax 7, retroperitoneal 4, paraspinal 2, extremity 1, pelvis 1, and head/neck 1). Human factors (n = 24), failure of policy/procedure (n = 21), and communication (n = 19) accounted for 64 (65%) of the 98 root causes identified. Conclusions Acquisition of surgical count technology did not significantly improve RSI rates. Soft good RSI events are associated with multiple disciplines and locations and the following dominant root causes: human factors, failure to follow policy/procedure, and communication.

Background: Injurious falls continue to challenge health care. Causes of serious falls from the largest health care system in the United States can direct future prevention efforts. Purpose: This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events. Methods: We categorized root cause analysis (RCA) reports and coded injury type, fall type, location, and root causes. We describe interventions during the fall and provide resources for future prevention. Results: There were 154 reported fall RCAs during this time. Most (83%, n = 128) resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116). Conclusions: Patients who fell were not wearing hip or head protection. Most falls were unwitnessed, and none were on 1:1 observation. Such interventions may help prevent future injurious falls.

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IntroductionSuicide is the 10th leading cause of death in the USA. Inpatient suicide is the fourth most common sentinel event reported to the Joint Commission. This study reviewed root cause analysis (RCA) reports of suicide events by hospital unit to provide suicide prevention recommendations for each area.MethodsThis is a retrospective analysis of reported suicide deaths and attempts in the US Veterans Health Administration (VHA) hospitals. We searched the VHA National Center for Patient Safety RCA database for suicide deaths and attempts on inpatient units, outpatient clinics and hospital grounds, between December 1999 and December 2018.ResultsWe found 847 RCA reports of suicide attempts (n=758) and deaths (n=89) in VHA hospitals, hanging accounted for 71% of deaths on mental health units and 50% of deaths on medical units. Overdose accounted for 55% of deaths and 68% of attempts in residential units and the only method resulting in death in emergency departments. In VHA community living centres, hanging, overdose and asphyxiation accounted for 64% of deaths. Gunshot accounted for 59% of deaths on hospital grounds and 100% of deaths in clinic areas. All inpatient locations cited issues in assessment and treatment of suicidal patients and environmental risk evaluation.ConclusionsInpatient mental health and medical units should remove anchor points for hanging where possible. On residential units and emergency departments, assessing suicide risk, conducting thorough contraband searches and maintaining observation of suicidal patients is critical. In community living centres, suicidal patients should be under supervision in an environment free of anchor points, medications and means of asphyxiation. Suicide prevention on hospital grounds and outpatient clinics can be achieved through the control of firearms.