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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

3019 — Sharing Lessons Learned to Prevent Incorrect Surgery

Neily JBMills PDPaull DEMazzia LM, and Turner JR, National Center for Patient Safety; Gunnar W, VA Central Office;

Objectives:
Wrong site surgery continues to occur despite the Joint Commission Universal Protocol and VHA policy. The National Center for Patient Safety (NCPS) and the National Surgery Office (NSO) collaborate to prevent such events. Incorrect surgery is considered a serious reportable event by the National Quality Forum, and an adverse event for which the Centers for Medicare and Medicaid (CMS) will not pay. The goal of this project is to summarize results so far of this approach to addressing this patient safety challenge.

Methods:
The NCPS has a reporting system for adverse events, and the NSO has recently developed (as of August 2010) a rapid notification system for timely capture of surgical adverse events. As of fiscal year 2010, the data from these reporting systems are reconciled quarterly to produce an adverse event report, including wrong site surgery. The NCPS produces a de-identified summary of lessons learned from surgery related root cause analyses (RCA). The quarterly surgery RCA lessons learned are distributed to VHA clinicians through the NSO organizational structure. The NSO developed regional interdisciplinary leadership groups of clinicians. This process facilitates discussions, and informs clinicians about how to improve and the development of strategies for prevention based on case study.

Results:
The VA has shared 54 cases of surgical adverse event lessons learned from FY10 through FY11 Q3. These included 21 retained item cases, 7 wrong-sided blocks, 7 wrong implants, 7 wrong-side/sites, 4 wrong spinal levels, 3 wrong dental cases, 2 wrong procedures, 1 wrong patient, and 2 wrong-sided thoracentesis.

Implications:
Feedback has been positive, and at the same time staff has indicated that further improvement on the dissemination method is needed. Sharing de-identified vignettes instead of only numbers has enriched the how to improve this issue.

Impacts:
These lessons learned have also informed the development of simulation training related to preventing adverse events. This is a promising method for addressing a persistent patient safety problem.


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