Surgical Errors Remain a Challenge In and Out of the
Operating Room
Communication problems often occur early and
interventions before incision often occur too late
Nov. 16, 2009 Surgical errors a significant
worry for the millions of senior citizens that must visit the operating
rooms of America each year continue to occur despite a national focus
on reducing them, says a an analysis of events at Veterans Health
Administration Medical Centers published in the November issue of
Archives of Surgery, one of the JAMA/Archives journals.
An estimated five to 10 incorrect surgical
procedures occur daily in the United States, some with devastating
effects. Surgery can be performed on the wrong site, wrong side of the
body, using an incorrect procedure or on the wrong patient.
"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," the authors write. The rule was further
updated in 2004.
Julia Neily, R.N., M.S., M.P.H., of Veterans Health
Administration (VHA), White River Junction, Vt., and colleagues reviewed
reported surgical adverse events occurring at 130 VHA facilities between
January 2001 and June 2006.
Events were categorized by location (inside the
operating room vs. outside, at a location such as a procedure room at a
clinic or at the patient's bedside), specialty departments, body
segments, severity and several other characteristics.
Overall, the researchers reviewed 342 reported
events, including 212 adverse events (any surgical procedure performed
unnecessarily, such as a procedure performed on the wrong patient or
wrong site) and 130 close calls (in which a recognizable step toward an
adverse event occurred but the patient was not subjected to the
unnecessary procedure).
Of the adverse events, 108 (50.9 percent) occurred
in an operating room and 104 (49.1 percent) occurred elsewhere.
"When examining just adverse events only,
ophthalmology and invasive radiology were the specialties associated
with the most reports - 45 (21.2%) each), whereas orthopedics was second
to ophthalmology for number of reported adverse events occurring in the
operating room," the authors write.
"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 %)."
The results indicate that communication problems
often occur early in surgical procedures, and interventions such as a
final "time-out" moments before incision may occur too late to correct
them.
"Incorrect surgical procedures are not only an
operating room challenge but also a challenge for events occurring
outside of the operating room," the authors conclude.
"We support earlier communication based on crew
resource management to prevent surgical adverse events."
This information is the result of work supported
with resources and the use of facilities at the Department of Veterans
Affairs National Center for Patient Safety at Ann Arbor, Mich., and the
Veterans Affairs Medical Center, White River Junction, Vt., and the
Department of Veterans Affairs Central Office, Washington, DC.
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Nov. 16, 2009 Surgical errors a significant
worry for the millions of senior citizens that must visit the operating
rooms of America each year continue to occur despite a national focus
on reducing them, says a an analysis of events at Veterans Health
Administration Medical Centers published in the November issue of
Archives of Surgery, one of the JAMA/Archives journals. 
