William Gunnar

Incorrect Surgical Procedures Within and Outside of the Operating Room: A Follow-up Report

OBJECTIVE To describe incorrect surgical procedures reported from mid-2006 to 2009 from Veterans Health Administration medical centers and build on previously reported events from 2001 to mid-2006. DESIGN Retrospective database review. SETTING Veterans Health Administration medical centers. INTERVENTIONS The Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety. MAIN OUTCOME MEASURES The categories 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. RESULTS Our review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P = .02). Reported close calls increased from 1.97 to 3.24 per month (P ≤ .001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%). CONCLUSIONS The rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed.

Using a Virtual Breakthrough Series Collaborative to Reduce Postoperative Respiratory Failure in 16 Veterans Health Administration Hospitals

BACKGROUND The Institute for Healthcare Improvement (IHI) Virtual Breakthrough Series (VBTS) process was used in an eight-month (June 2011-January 2012) quality improvement (QI) project to improve care related to reducing postoperative respiratory failure. The VBTS collaborative drew on Patient Safety Indicator 11: Postoperative Respiratory Failure Rate to guide changes in care at the bedside. METHODS Sixteen Veterans Health Administration hospitals, each representing a regional Veterans Integrated Service Network, participated in the QI project. During the prework phase (initial two months), hospitals formed multidisciplinary teams, selected measures related to their goals, and collected baseline data. The six-month action phase included group conference calls in which the faculty presented clinical background on the topic, discussed evidence-based processes of care, and/or presented content regarding reducing postoperative respiratory failure. During a final, six-month continuous improvement and spread phase, teams were to continue implementing changes as part of their usual processes. RESULTS The six most commonly reported interventions to reduce postoperative respiratory failure focused on improving incentive spirometer use, documenting implementation of targeted interventions, oral care, standardized orders, early ambulation, and provider education. A few teams reported reduced ICU readmissions for respiratory failure. CONCLUSIONS The VBTS collaborative helped teams implement process changes to help reduce postoperative respiratory complications. Teams reported initial success at implementing site-specific improvements using real-time data. The VBTS model shows promise for knowledge sharing and efficient multifacility improvement efforts, although long-term sustainability and testing in these and other settings need to be examined.

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration

BACKGROUND The Universal Protocol has been associated with the prevention of wrong surgery procedures; however, such events still occur. This article explores wrong surgery events, defined as those incorrect procedures (wrong site, wrong side, wrong procedure, wrong patient, wrong level, wrong implant) that would have occurred despite the Universal Protocol including the performance of a time-out by the surgical team. Understanding why some of these events are not caught by the steps of the Universal Protocol, culminating in the time-out, can help the field to add upstream and downstream safeguards to help prevent these never events. METHODS The Veterans Health Administration database of root cause analyses was queried for all cases involving an incorrect surgical procedure between 2004 and 2013 to determine the relative frequency and characteristics of wrong surgery events because of errors upstream and downstream to the Universal Protocol. This subgroup of wrong surgery events was selected from among all the wrong surgery events by 2 clinicians with expertise in patient safety (Kappa = .91). RESULTS Forty-eight cases of wrong surgery events because of upstream/downstream errors were analyzed, representing 16% of the 308 root cause analyses for wrong surgery events reported during this period. Upstream errors included mislabeling of specimens, while downstream errors were associated with ineffective intraoperative process. Surgical procedures that were particularly vulnerable included wrong level spine operations, wrong patient prostatectomies, wrong implant cataract procedures, and wrong site skin lesion excisions. CONCLUSIONS Wrong surgery events can and do occur despite adherence to Universal Protocol including a time-out. The prevention of incorrect procedures requires complementary safety behaviors and technologies to address errors that occur upstream and downstream to the Universal Protocol and the time-out.

Preventing wrong-site invasive procedures outside the operating room: a thoracentesis simulation case scenario.

Case Title: Thoracentesis at the BedsideVEnsuring Correct Invasive Procedures Patient Name: Ritchie Hernandez Case Description and Diagnosis: A 62-year-old man with fever, dyspnea, and a right pleural effusion undergoes a thoracentesis. Successful completion of the procedure is challenged by distractions, incorrect medical images, and the development of a tension pneumothorax. Date of Development: December 2010 Target Audience: Residents, attending physicians, nurses, and technicians involved in the care of patients undergoing invasive procedures (eg, medicine, surgery, invasive radiology)

Trends in the Purchase of Surgical Care in the Community by the Veterans Health Administration (VA)

Background: The 2014 implementation of the Veterans Choice Program increased opportunities for Veterans to receive care in the community. Although surgical care is a Veterans Health Administration (VHA) priority, little is known about the types of surgeries provided in the VHA versus those referred to community care (CC), and whether Veterans are increasing their use of surgical care through CC with these additional opportunities. Objectives: To examine national trends across VHA facilities in the frequencies and types of surgeries provided in the VHA and through CC, and explore the association between facilities’ purchase of care with rurality and surgical complexity designation. Research Design: Retrospective study using Veterans Administration (VA) outpatient and CC data from the VA’s Corporate Data Warehouse (October 1, 2013–September 30, 2016). Measures: Veterans’ demographics, outpatient surgeries, facility rurality, and surgical complexity. Results: Our sample included 525,283 outpatient surgeries; 79% occurred in the VHA over the study timeframe. The proportion of CC surgeries increased from 16% in October 2013 to 29% in December 2014, and then subsequently declined, leveling off at 21% in June 2016 (trend, P<0.05). These trends varied by surgery type. Increases in CC surgeries were evident for 4 surgery types: cardiovascular, digestive, eye and ocular, and male genital surgeries (all trends, P<0.05). Rural and low-complexity facilities were more likely to purchase surgical CC than their urban and high-complexity counterparts (P<0.0001). Conclusions: Although the VHA remains the primary provider of surgical care for Veterans, Veterans Choice Program implementation increased Veterans’ use of CC relative to the VHA for certain types of surgeries, potentially bringing challenges to the VHA in delivering and coordinating surgical care across settings.

Examining Wrong Eye Implant Adverse Events in the Veterans Health Administration With a Focus on Prevention: A Preliminary Report.

Objective The study goals were to examine wrong intraocular lens (IOL) implant adverse events in the Veterans Health Administration (VHA), identify root causes and contributing factors, and describe system changes that have been implemented to address this challenge. Design This study represents collaboration between the VHAs National Center for Patient Safety (NCPS) and the National Surgery Office (NSO). Participants This report includes 45 wrong IOL implant surgery adverse events reported to established VHA NCPS and NSO databases between July 1, 2006, and June 31, 2014. There are approximately 50,000 eye implant procedures performed each year in the VHA. Methods Wrong IOL implant surgery adverse events are reported by VHA facilities to the NCPS and the NSO. Two authors (A.C. and J.N.) coded the reports for event type (wrong lens or expired lens) and identified the primary contributing factor (coefficient &kgr; = 0.837). A descriptive analysis was conducted, which included the reported yearly event rate. Main Outcome Measure The main outcome measure was the reported wrong IOL implant surgery adverse events. Results There were 45 reported wrong IOL implant surgery adverse events. Between 2011 and June 30, 2014, there was a significant downward trend (P = 0.02, R2 = 99.7%) at a pace of −0.08 (per 10,000 cases) every year. The most frequently coded primary contributing factor was incomplete preprocedure time-out (n = 12) followed by failure to perform double check of preprocedural calculations based upon original data and implant read-back at the time the surgical eye implant was performed (n = 10). Conclusions Preventing wrong IOL implant adverse events requires diligence beyond performance of the preprocedural time-out. In 2013, the VHA has modified policy to ensure double check of preprocedural calculations and implant read-back with positive impact. Continued analysis of contributing human factors and improved surgical team communication are warranted.

Universal Health Insurance: will it control the cost of U.S. health care?

285 PLAIN AND SIMPLE,THE COST of health care in the United States is at the core of the debate over health care reform in the months leading to the 2008 U.S. Presidential election. U.S. health care costs too much, and the cost of paying for health care can be blamed for unacceptably high corporate overhead, record numbers of uninsured, and increasing demands on the federal and state governments to limit entitlement programs. David F. Drake’s Mandate for 21st Century America: Universal Health Insurance proposes an income-based tax-financed catastrophic universal health insurance benefit with government oversight on provider activity. In theory, such health care reform would allow free-market forces to bring the cost of health care under control. However, universal health insurance as Drake describes will do little to control health care costs; moreover, implementation of this plan may have unintended deleterious consequences. Drake and I approach the debate over health care reform from different per-

Understanding the Complexity of the U. S. Health Care System: Can Free Market Ideology Respond to a Current Challenge?

149 IAM A THIRD-GENERATION PHYSICIAN, a baby boomer, a parent, an American citizen, and a taxpayer. Since my recitation of the Hippocratic Oath 28 years ago during medical school orientation, I have found employment in the academic, federal, and private health care arenas. I am fiscally conservative, socially liberal, and a great believer in the U.S. Constitution. I am dependent upon the U.S. health care system for my livelihood, for my personal health care and the health care of my loved ones and their progeny, and philosophically for the health care of all people. Neither I nor my family has ever been without health care insurance.A discussion of politics and government policy demands a declaration of perspective. The third edition of Governing Health:The Politics of Health Policy provides a

Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration

This quality improvement project describes 22 OR patient falls reported in the Veterans Health Administration between January 2010 and February 2016. Most (n = 15; 68%) involved patient falls from the OR bed. Other patient falls (n = 6; 27%) occurred when the patient was transferred to or from the OR bed, and one fall (5%) occurred at another time. Root causes of the falls included tilting of the OR bed, issues with safety restraints, malfunctioning OR bed or gurney locks, inadequate patient sedation, and poor communication among team members. One fall (5%) resulted in a major injury, four falls (18%) resulted in minor injuries, six falls resulted in no injury, and 11 falls (50%) had no reported outcome. Falls in the OR, although rare, can be injurious. We drafted recommendations based on the root causes that include specific guidance on communication, teamwork, best practices, restraints and equipment, and training.