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Surgery Errors in Veterans Hospitals Studied

Last Updated: November 19, 2009.

Errors during ophthalmologic and orthopedic surgeries were the most common found in a study of surgery errors occurring in veterans hospitals, according to a study in the November issue of the Archives of Surgery.

THURSDAY, Nov. 19 (HealthDay News) -- Errors during ophthalmologic and orthopedic surgeries were the most common found in a study of surgery errors occurring in veterans hospitals, according to a study in the November issue of the Archives of Surgery.

Julia Neily, R.N., of the Department of Veterans Affairs in White River Junction, Vt., and colleagues assembled data on incorrect surgical procedures reported by Veterans Health Administration Medical Centers from 2001 to mid-2006. The study looked at error categories (wrong patient, side, site, procedure, etc.), whether it was major or minor surgery, adverse events or close calls, severity/probability of harm, and other issues.

The researchers identified 342 error reports, including 212 adverse events (108 in the operating room and 104 elsewhere) and 130 close calls. For adverse events, ophthalmology and invasive radiology were tied with 45 reports each, followed by orthopedics with 26 reports, and urology with 23 reports. Errors in pulmonary medicine cases (for example, wrong-side thoracentesis) and wrong-site cases (such as surgery on the wrong part of spine) were associated with the most harm. Miscommunication was the most common cause for errors (21.0 percent).

"Incorrect ophthalmic and orthopedic surgical procedures appear to be overrepresented among adverse events occurring in operating rooms. Outside the operating room, adverse events by invasive radiology were most frequently reported. Incorrect surgical procedures are not only an operating room challenge but also a challenge for events occurring outside of the operating room. We support earlier communication based on crew resource management to prevent surgical adverse events," the authors write.

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