3081 — Using Lessons from Root Cause Analysis to Enhance the Safety of Surgical Procedures
Neily JB (Field Office, NCPS), Mills PD
(Field Office, NCPS), Eldridge N
(NCPS), Dunn EJ
(NCPS), Samples C
(NCPS, retired), Turner JR
(NCPS), Revere A
(NCPS), Weeks WB
(Field Office, NCPS), DePalma RG
(Central Office), Bagian JP
Surgical adverse events can be devastating. Despite efforts to eliminate incorrect surgery, these events continue to occur. We examined Root Cause Analysis (RCA) and safety reports of VA surgical events that occurred between January 1, 2001 and June 30, 2006.
The VA instituted an initial directive on “Ensuring Correct Surgery”, January 2003 and updated it in 2004 to include non-operating room invasive procedures. All serious adverse events in VA hospitals are analyzed using an RCA while less-serious events are reported using safety reports. Reports concerning "wrong site, wrong patient, wrong procedure” surgical events were categorized by two independent teams to reveal descriptive information about events and the level of harm (kappa=91).
We received reports of 108 adverse events that occurred in the operating room and 104 adverse events that occurred elsewhere. Ophthalmology and Invasive Radiology were associated with the most reports of adverse events: 45 (22%) each, with most Ophthalmology cases being in-OR and most Invasive Radiology cases being non-OR. The two most commonly reported types of adverse events were “wrong patient” outside of the OR (47 reports) and “wrong side” inside the OR (44 reports). When both settings were combined, wrong side outnumbered wrong patient: 66 (31%) to 56 (26%); the remainder were wrong implant (20%), wrong site (15%), or wrong procedure (8%) cases. Thoracic cases (such as wrong side thoracentesis) and wrong site cases (such as wrong spinal level) were associated with most harm (Chi Squared=12.45,p < .0001) and (Chi Squared=4.81,p=.028) respectively.
Wrong patient cases outside the OR and wrong side cases inside the OR are the most commonly reported adverse events in this area, and ophthalmology and invasive radiology reported the most adverse events. Thoracic and wrong site cases were associated with higher harm.
These insights provide direction for ensuring correct surgery, including a focus on thoracic cases and site verification to reduce harm and on ophthalmology and invasive radiology to reduce number of events. Cases outside of the OR are about as commonly reported as inside the OR, and clinicians should use these results to focus new efforts to prevent incorrect surgical procedures reported in each setting.