As per an analysis of events at Veteran Heath Administration Medical Centers, in spite of the national focus on decreasing surgical errors, surgery-related unfavorable events apparently persist both within and outside the operating room.
Approximately 5 to 10 wrong surgical procedures supposedly take place every day in the United States, and few with apparently disturbing results. Surgery may be carried out on the incorrect place, mistaken side of the body, via an erroneous process or on the wrong patient.
The authors commented, “The Veterans Health Administration developed and implemented a pilot program to reduce the risk of incorrect surgical events in April 2002, which resulted in the dissemination of a national directive in January 2003.”
Julia Neily, R.N., M.S., M.P.H., of Veterans Health Administration (VHA), White River Junction, Vt., and colleagues supposedly analyzed reported surgical unfavorable events taking place at about 130 VHA facilities between January 2001 and June 2006. The proceedings were supposedly classified by the setting i.e. in the operating room vs. outside, at a place like a procedure room at a clinic or at the patient’s bedside. The others included specialty departments, body segments, severity and various other characteristics.
By and large, the researchers apparently examined about 342 reported events, counting about 212 adverse events i.e. any surgical procedure carried out needlessly and around 130 close calls in which a familiar step toward an unfavorable event took place but the patient was supposedly not subjected to a pointless procedure. Of the unfavorable events, around 108 surgeries took place in an operating room and 104 occurred elsewhere.
The authors remarked, “When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2 percent] each), whereas orthopedics was second to ophthalmology for number of reported adverse events occurring in the operating room. Pulmonary medicine cases (such as wrong-side thoracentesis [removing fluid from chest]) and wrong-site cases (such as wrong spinal level) were associated with the most harm. The most common root cause of events was communication (21.0 percent).”
The outcomes apparently signify that communication issues could frequently arise early in surgical procedures, and interventions like a final ‘time-out’ moments prior to incision may crop up too late to rectify them.
The authors stated, “Incorrect surgical procedures are not only an operating room challenge but also a challenge for events occurring outside of the operating room.”
The authors concluded by mentioning that they support earlier communication based on crew resource management to prevent surgical adverse events.
The study was published in the Archives of Surgery, one of the JAMA/Archives journals.