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Incorrect Surgical Procedures Within and Outside of the Operating Room
Julia Neily, RN, MS, MPH;
Peter D. Mills, PhD, MS;
Noel Eldridge, MS;
Edward J. Dunn, MD, MPH;
Carol Samples, BGS;
James R. Turner, BS;
Audrey Revere;
Ralph G. DePalma, MD;
James P. Bagian, MD, PE
Arch Surg. 2009;144(11):1028-1034.
Objective To describe incorrect surgical procedures reported from Veterans Health Administration (VHA) Medical Centers from 2001 to mid-2006 and provide proposed solutions for preventing such events.
Design Descriptive study.
Setting Veterans Health Administration Medical Centers.
Participants Veterans of the US Armed Forces.
Interventions The VHA instituted an initial directive, "Ensuring Correct Surgery and Invasive Procedures," in January 2003. The directive was updated in 2004 to include non–operating room (OR) invasive procedures and incorporated requirements of The Joint Commission Universal Protocol for preventing wrong-site operations.
Main Outcome Measures The categories included 5 incorrect event types (wrong patient, side, site, procedure, or implant), major or minor surgical procedures, location in or out of the OR, therapeutic or diagnostic events, adverse event or close call, inpatient or ambulatory events, specialty department, body segment, and severity and probability of harm.
Results We reviewed 342 reported events (212 adverse events and 130 close calls). Of these, 108 adverse events (50.9%) occurred in an OR, and 104 (49.1%) occurred elsewhere. When examining 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 OR. Pulmonary medicine cases (such as wrong-side thoracentesis) 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%).
Conclusions Incorrect ophthalmic and orthopedic surgical procedures appear to be overrepresented among adverse events occurring in ORs. Outside the OR, adverse events by invasive radiology were most frequently reported. Incorrect surgical procedures are not only an OR challenge but also a challenge for events occurring outside of the OR. We support earlier communication based on crew resource management to prevent surgical adverse events.
Author Affiliations: Department of Veterans Affairs, Veterans Health Administration (Mss Neily, Samples, and Revere; Drs Mills, Dunn, DePalma, and Bagian; and Messrs Eldridge and Turner); Department of Psychiatry, Dartmouth Medical School, Hanover, New Hampshire (Dr Mills); Department of Surgery, Uniformed Services University of the Health Sciences (Dr DePalma), and Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine (Dr Bagian), Bethesda, Maryland; and Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston (Dr Bagian).
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