Incorrect Surgical Procedures Within and Outside of the Operating Room

Abstract

Interventions:The Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety. Main Outcome Measures:The categories were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm.Results: Our review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P=.02). Reported close calls increased from 1.97 to 3.24 per month (P Յ.001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%). Conclusions:The rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed.

Use of the American Academy of Ophthalmology Surgical Checklist and Implant Timeouts: An Online Survey of Connecticut Ophthalmologists

“…This is despite the persistently high number of ophthalmologists, 25% in our survey, committing system errors at least once in their surgical careers. Consistent with a previous study [11], there was no correlation between adverse events and the use of a checklist or timeout, which may signify the need for a more relevant ophthalmic surgical checklist than the ones currently in use. However, the AAO's effort [9] in 2012 that produced a template for such a checklist has largely gone unnoticed, as 83% of the ophthalmologists in the current survey reported being unaware of it.…”

“…The low adherence may also be explained by the yet unproven benefit of checklists in ophthalmology. For example, the rate of ophthalmology related adverse events remained high after the VHA implemented an intervention designed to improve communication and patient safety in the OR [11]. Similarly, we found no correlation between at least one incident of adverse event and the use of checklists or implant timeouts in our survey.…”

“…In a Veterans Health Administration (VHA) report describing incorrect surgical events from 2000 to 2006, ophthalmology had the highest overall number and rate of surgical adverse events [8]. Even with presumed underreporting of such events, Simon et al found 62 cases of "surgical confusions" upon review of the 900,000 eye operations performed in New York State between 2000 and 2005, a rate that is 10 times the six-sigma standard and unacceptably high for events termed "never events" [5].…”

“…The Veterans Health Administration (VHA) found that from 2001-2006, ophthalmology was responsible for the highest rate of operative adverse events amongst all surgical specialties in their centers [8]. While incorrect implantation of intraocular lenses (IOL) accounts for the majority of these errors, incorrect operations, incorrect eye blocks, incorrect eye on which the operation is performed, and retained surgical items are all reported surgical errors in ophthalmology [5][6][7][8].…”

“…While incorrect implantation of intraocular lenses (IOL) accounts for the majority of these errors, incorrect operations, incorrect eye blocks, incorrect eye on which the operation is performed, and retained surgical items are all reported surgical errors in ophthalmology [5][6][7][8]. Most authors concur that a substantial number of these errors-up to 85% in one case series [5] -are preventable, given an appropriate system-wide intervention.…”