The rate of adverse events and harm reported at Veterans Health Administration medical centers appears to have decreased, according to a report.
The article represents a follow-up report to research on surgical adverse events in the VHA system from 2001 to mid-2006, and also includes information about recent system-wide interventions such as Medical Team Training.
“Medical Team Training requires two months of planning with a core change team, a one-day face-to-face learning session where surgery is put on hold (and attendance by the OR team is mandated), and 12 months of follow-up and coaching,” the authors wrote. “A key component of MTT is the emphasis on conducting preoperative briefings and postoperative debriefings, both guided by a checklist. One of the goals of the MTT program was to reduce the in-OR incorrect surgeries in VHA medical centers.”
Julia Neily, RN, MS, MPH, from the VHA in White River Junction, Vt., and colleagues reviewed the VA National Center for Patient Safety database, looking for surgical adverse events and close calls that occurred between July 2006 and December 2009. The researchers coded cases into categories (type of event, body segment, etc.) and root causes, and then reached consensus.
Of the 237 reports that the researchers identified, 101 were adverse events and 136 were close calls. Roughly half the adverse events took place in the OR, but their severity, on average, decreased. A significant decrease in the number of adverse events per month was reported (2.4 in this study versus 3.21 in the previous study), whereas close calls increased from 1.97 reports per month to 3.24.
The authors determined that 204 root causes contributed to the adverse events, the most common cause being lack of standardization of clinical processes. The rate of “highest harm” adverse events decreased by 14% annually.
The authors suggest possible reasons for the decline in adverse events, such as a greater emphasis on safety, team training and communication.
“Despite the overall decrease in patient harm, opportunities exist to further decrease the number of incorrect surgical and invasive procedures,” they wrote. “We must continue to improve.”
The report appears on the website of the Archives of Surgery: http://archsurg.ama-assn.org/cgi/content/full/archsurg.2011.171.