Decrease in Rate of Surgical Adverse Events in VHA Centers
From 2006 to 2009, rate of adverse events decreased but rate of close calls increased
THURSDAY, July 21 (HealthDay News) -- The rate of adverse events for surgical procedures and harm in the Veterans Health Administration (VHA) system decreased from 2006 to 2009 while reported close calls increased, according to a study published online July 18 in the Archives of Surgery.
Julia Neily, R.N., M.P.H., from the Veterans Health Administration in White River Junction, Vt., and colleagues examined adverse surgical events and close calls reported in the VHA system and the impact of the Medical Team Training program on outcome measures. Data were collected from mid-2006 to 2009 and outcomes compared with a previous report (from 2001 to mid-2006). The outcome measures were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm.
The investigators identified a total of 237 reports (101 adverse events and 136 close calls) that showed an overall decline in harm as compared with the previous report. There was a significant decrease in the rate of reported adverse events (from 3.21 to 2.4 per month) but a significant increase in the number of close calls (from 1.97 to 3.24 per month). Equal incidence of adverse events was observed in OR (50) and non-OR settings (51). In the OR, reported adverse events per 10,000 cases were 1.56 for neurosurgery and 1.06 for ophthalmology. At 18 percent, the lack of standardization of clinical processes was the most common cause of adverse events.
"The rate of reported adverse events and harm decreased, while reported close calls increased," the authors write.