VA staff continue to report and investigate surgical and invasive adverse events and report close calls.
At all VA medical centers, doctors, nurses and other hospital workers are required to report medical errors and near misses. That requirement, along with VA’s quality improvement efforts, is helping VA improve its patient safety record.
A new Department of Veterans Affairs report shows that it’s working.
“The rate of reported actual adverse events per month and the severity of those events has significantly diminished in the operating room,” noted Julia Neily, a nurse, lead author of the report, and associate director of VA’s National Center for Patient Safety Field Office.
Between mid-2006 and 2009, staff reported 101 surgical adverse events and 136 surgical close calls from both in and out of operating room settings.
The report shows a decrease in reported adverse events from 3.21 to 2.4 per month, while reported close calls increased from 1.97 to 3.24 per month.
“Care is becoming safer.”
— Julia Neily, Associate Director, National Center for Patient Safety Field Office
Reporting “Close Calls” Essential to Patient Safety
The findings indicate that VA staff continue to report and investigate surgical and invasive adverse events and report close calls, which allows problems to be caught before any harm occurs.
Close calls occur anywhere from three to 300 times more often than actual adverse events and in VA are given the same level of scrutiny as adverse events that result in harm to a patient.
“An increase in close call reporting is a very positive sign,” Neily said. “A willingness to report problems is essential to safe care.”
She said the increase in close call reports indicates that doctors, nurses, and their co-workers are now more willing to speak up if something goes wrong, or if it looks like something could go wrong.
“Care is becoming safer,” she added.
The data were derived from VA’s National Center for Patient Safety Database, which was developed to provide a confidential, non-punitive reporting system that allows users to electronically document patient safety information so lessons learned can benefit the entire system.
Goal: Prevent Mistakes from Happening Again
The root cause analysis process is a multidisciplinary team approach used to study adverse medical events and close calls. The goal of each root cause analysis is to find out what happened, why it happened, and what must be done to prevent it from happening again.
Many possible reasons for the decrease in adverse events were noted, including an increased focus on operating room safety in VA medical centers, and the implementation of the Medical Team Training (MTT) program at VA medical centers nationwide. MTT was developed to improve patient outcomes through more effective communication and teamwork among providers.
The most common root cause for incorrect surgery noted in the current report was a clinical process being left to the judgment of a clinician to accomplish, rather than having a specific approach to that process the clinician could have followed.
Human factors problems were the second most common root cause. These included issues with the human-machine interface, look-alike packaging of different implant components, and fatigue.
Commitment to Improve Communication
VA is implementing several initiatives to prevent incorrect surgical procedures in collaboration with VA surgical leadership. Other efforts include team training for staff in non-operating room settings, such as cardiac catheterization labs, and a sustained commitment to improve communication and teamwork through programs such as MTT.
“We are going to continue to seek ways reduce wrong site surgery,” said Neily, “It’s an essential part of VA’s goal to reduce harm to patients as a result of their care.”
The Veterans Affairs report was published in the Archives of Surgery online edition, July 18, 2011.