Poor communication causes most mistakes in and out of operating room.

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Errors in Surgical Procedures Persist

Poor communication causes most mistakes in and out of operating room, VA study shows

By Steven Reinberg
HealthDay Reporter

http://health.usnews.com/articles/health/healthday/2009
/11/19/errors-in-surgical-procedures-persist.html

(HealthDay News) -- The U.S. Veterans Administration has taken the lead in improving patient safety, but its efforts are still a work in progress as surgical errors in and out of the operating room persist, a new study shows.

Each day in the United States, there are five to 10 incorrect surgical procedures performed, some with devastating effects, the researchers noted. Typical problems are surgery performed on the wrong site or wrong side of the body, using an incorrect procedure or using it on the wrong patient.

"In 2003, we put out a directive that said this is the way you are going to do it, if you are going to minimize the chance of things happening," said lead researcher Dr. James P. Bagian, director of the VA National Center for Patient Safety.

"Up until today, I can tell you, we have not had any reports where people have followed the procedures as they're written and ever had one of these problems," he said.

The report is published in the November issue of the Archives of Surgery.

For the study, Bagian's group reviewed 342 surgical problems from 130 VA hospitals from 2001 to the middle of 2006. Problems were divided into those happening in the operating room and those happening outside the operating room. Typically, these procedures were done in VA clinics or at the patient's bedside.

Among the cases the researchers looked at were 212 adverse events, where wrong procedures were performed or the procedure was performed in the wrong patient, or at the wrong site. In addition, there were 130 "close calls," where a problem was recognized before the procedure was done.

"A close call, where they said by following the procedure we caught this, I count that as a save," Bagian noted.

Adverse events occurred once in every 18,000 procedures, Bagian said.

The most common cause of errors was poor communication among the surgical team members, Bagian said. This accounted for 21 percent of the problems. These communication problems often happen early in surgical procedures, and interventions such as a final "time-out" moment before making the first incision may be too late to correct them, the researchers noted.

Of the adverse events, 50.9 percent occurred in the operating room and 49.1 percent occurred elsewhere. The most adverse event reports were in ophthalmology and invasive radiology (21.2 percent). Orthopedics
accounted for the second highest rate of problems in the operating room, after ophthalmology.

The most harm was caused by pulmonary
cases where fluid was removed from the wrong side of the chest or the procedure was done at an incorrect place on the chest, the researchers said.

Bagian noted that good numbers for evaluating medical errors are hard to come by. It may be that the specialties reporting the most errors are just more honest, he said, or their mistakes are harder to hide.

The VA continues to evaluate problems and work toward an even better safety record, Bagian said.

Dr. Jeffrey M. Rothschild, an associate physician at Brigham and Women's Hospital, and an instructor in medicine at Harvard Medical School, said the "VA system is further ahead than most places so finding as many as they did makes you wonder how many one would find in community and academic centers."

Rothschild thinks that more care needs to be taken in making sure the procedure, the patient and the site for the procedure are right before starting any procedure.

"Our systems are still not robust enough to prevent human error from slipping through," he said.

There is probably more cases of surgical error outside the VA, Rothschild said. "The VA is probably less of an issue, because they were one of the first systems to really take on safety," he said. "The VA system is better and more advanced."

More information

For more information on patient safety, visit the Joint Commission.

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TOPICS: veterans, veterans' benefits, VA, Department of Veterans' Affairs, research, surgical errors