Wrong surgery down, close calls up at VA hospitals

CHICAGO – Medical procedures and surgeries on the wrong patient and wrong body part have declined substantially at Veterans Affairs hospitals nationwide, while reports of close calls have increased, according to a study that credits ongoing quality improvement efforts.

These efforts include a VA requirement for doctors, nurses and other hospital workers to report medical errors and near-misses to their bosses. The study is based on reports from mid-2006 to 2009; they were compared with data from the previous five years.

The per-month rate of reported errors declined to about two from about three at the VA's 153 centers that do surgery or other major medical procedures. Reported monthly close calls increased to about three from almost two.

Skeptics might wonder if a decline in reported errors means hospital workers are clamming up, but co-author Julia Neily, a nurse and associate director with the VA's National Center for Patient Safety, said, "Care is becoming safer." She said the increase in close-call reports suggests doctors, nurses and their co-workers are becoming more willing to speak up when something goes wrong or looks like it's about to.

The VA's quality improvement efforts encourage that kind of openness. Veterans facilities also are among hospitals that have adopted pilot-style checklists, where a member of the operating team reads off things like the patient's name, the type of procedure, anesthesia and tools needed. Body parts to be operated on are marked, and team members are supposed to speak up if something doesn't sound right. Patients, too, are sometimes involved before being wheeled into the operating room.

The study was published online Monday in the Archives of Surgery.

During the 42 months studied, there were 101 medical errors and 136 close calls, out of more than half a million procedures.

The researchers and patient safety experts not involved in the study said the results show a promising trend, including a decline in the severity of medical errors at VA hospitals.

Still, there were troubling signs — 30 procedures or surgeries on the wrong patient and 48 on the wrong body part or wrong side of the body.

Most "wrong patient" events involved CT scans, MRIs and other radiology procedures. "Wrong" surgeries included implanting the wrong size eye lens and the wrong type of knee joint.

Why these major errors continued to happen despite a big focus on improving safety "is THE question," Neily acknowledged.

Sometimes patients have the same or similar names, she said.

Sometimes patients speak different languages or otherwise have difficulty communicating with their doctors, said Dr. Allan Frankel of the Institute for Healthcare Improvement, who stressed that non-VA hospitals are also struggling to get those numbers down to zero after adopting similar systems.

Dr. David Mayer, co-director of the Institute for Patient Safety Excellence at the University of Illinois at Chicago, said sometimes surgeons and other OR team members are distracted during "time-outs" and checklist-reading before surgeries, thinking ahead to the operation.

At UIC's medical center, surgeons are encouraged to have these sessions outside the operating room, in a quiet setting around patients' beds, to make it easier to focus, Mayer said. Some VA hospitals also use that approach, Neily said.

The study lacked data on deaths related to surgery mistakes during the study, although the authors said there were no deaths in 2009, the most recent year examined.

A 2006-08 study published last year reported an 18 percent decline in deaths at 74 Veterans hospitals that had adopted the surgery checklist approach.

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