The study looked at 101 adverse events and 136 close calls reported between mid-2006 and 2009 and found decreased harm compared with the previous report. The rate of reported adverse events dropped from 3.21 to 2.4 per month. During that same period, the rate of reported close calls rose from 1.97 per month to 3.24 per month. Adverse events were evenly split between OR and non-OR. This time, instead of communication being cited as the most common root cause of adverse events, it was lack of standardization of clinical processes.

The researchers cite VA’s Medical Team Training (MTT) initiative as a key factor in improving communication and, subsequently, lowering adverse surgical events. Implemented nationally between 2006 and 2009, MTT targeted OR personnel at VA medical centers that had a surgical program.

The highlight of the program is a full-day learning session that introduces aviation-based crew resource management (CRM) communication tools to the surgical team. The same communication tools used to get commercial airliners into the sky and safety back on the ground are applied to the healthcare setting. MTT program participation includes two months of preparation and planning and a minimum of 12-months of follow-up, with quarterly interviews, coaching and a follow-up questionnaire.

Studies looking specifically at sites with MTT training programs have found the program to be directly linked with decreased surgical mortality.

Room for Improvement

Researchers commented in the study that, while VA has improved in this area, there is still much room for improvement.

Ophthalmology continues to have one of the highest rates of adverse events. Many of those incidents dealt with the implanting of the wrong corrective lenses. In some cases, surgical teams had the correct implant in the room before the procedure but also had several other lenses present, which contributed to the error. Other times, the wrong lens was obtained due to incorrect patient data.

Neurology also had a high rate of reported adverse events — all of which were spine cases. As of May, VA has updated its procedures to require greater specificity during surgery, including having the attending surgeon personally confirm the position of the spine marker prior to surgery. The hope is that such care will help prevent adverse events during spinal surgery.

Researchers said they are targeting the lack of standardized processes commonly cited as the root cause of adverse events in this newest study. Data gleaned from the report is being shared with regional surgical leaders and VA leadership to see what lessons can be learned from this investigation.

2009 study

New study

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