WHITE RIVER JUNCTION, VT — How common are adverse events related to gastrointestinal (GI) scope and tube placement procedures at the VHA?
A new study published in the Journal of Patient Safety provides some answer to that question for a the time period between January 2010 and June 2012.1
Researchers from the White River Junction field office of the VHA’s National Center for Patient Safety and colleagues created a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the healthcare system’s database. Adverse event type, procedure, location, severity and frequency were extracted, and associations between types of adverse events and harm levels were determined.
To do that, the study team reviewed 27 cases of reported adverse events related to GI invasive procedures. Of the 25 adverse events for which location could be determined, 40% were in the operating room, and 60% occurred in other locations.
Overall, endoscopies were associated with the least amount of harm, according to the report.
Results indicated that the most frequently reported adverse event types were human factors, 22%, followed by retained items, 18.5%. Retained item events were associated with the most harm, however.
The study team found that the most common root causes were lack of standardization in the process of care and suboptimal communication.
“Efforts to reduce adverse events during GI invasive procedures include improving situational awareness of the risk of retained items, standardization of care, communication between providers, and inspection of instruments for intactness before and after procedures,” study authors concluded.
- Soncrant C, Mills PD, Neily J, Paull DE, Hemphill RR. Root Cause Analyses of Reported Adverse Events Occurring During Gastrointestinal Scope and Tube Placement Procedures in the Veterans Health Association. J Patient Saf. 2017 Mar 3 doi: 10.1097/PTS.0000000000000236. [Epub ahead of print] PubMed PMID: 28257288.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.