Errors in Surgical Procedures Persist
Nov. 20 -- THURSDAY, Nov. 19 (HealthDay News) -- The U.S. Veterans Administration has taken the lead in improving patient safety, but its efforts are still a work in progress as surgical errors in and out of the operating room persist, a new study shows.
Each day in the United States, there are five to 10 incorrect surgical procedures performed, some with devastating effects, the researchers noted. Typical problems are surgery performed on the wrong site or wrong side of the body, using an incorrect procedure or using it on the wrong patient.
"In 2003, we put out a directive that said this is the way you are going to do it, if you are going to minimize the chance of things happening," said lead researcher Dr. James P. Bagian, director of the VA National Center for Patient Safety.
"Up until today, I can tell you, we have not had any reports where people have followed the procedures as they're written and ever had one of these problems," he said.
The report is published in the November issue of the Archives of Surgery.
For the study, Bagian's group reviewed 342 surgical problems from 130 VA hospitals from 2001 to the middle of 2006. Problems were divided into those happening in the operating room and those happening outside the operating room. Typically, these procedures were done in VA clinics or at the patient's bedside.
Among the cases the researchers looked at were 212 adverse events, where wrong procedures were performed or the procedure was performed in the wrong patient, or at the wrong site. In addition, there were 130 "close calls," where a problem was recognized before the procedure was done.
"A close call, where they said by following the procedure we caught this, I count that as a save," Bagian noted.
Adverse events occurred once in every 18,000 procedures, Bagian said.
The most common cause of errors was poor communication among the surgical team members, Bagian said. This accounted for 21 percent of the problems. These communication problems often happen early in surgical procedures, and interventions such as a final "time-out" moment before making the first incision may be too late to correct them, the researchers noted.
