Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers.

INTRODUCTION: Adverse events in urologic procedures are poorly studied. This study analyzes the Veterans Health Administration (VHA) Root Cause Analysis (RCA) data for patient safety adverse events during urologic procedures performed in a VHA operating room (OR). MATERIALS AND METHODS: The VHA National Center for Patient Safety RCA database was queried for fiscal years 2015-2019 using urologic terms including vasectomy, prostatectomy, nephrectomy, cystectomy, cystoscopy, lithotripsy, ureteroscopy, urethral, TURBT, etc. RCAs for events outside a VHA OR were excluded. Cases were categorized based on type of event. RESULTS: Sixty-eight RCAs were identified for 319,713 urologic procedures. The most common pattern identified was equipment or instrument issue, including broken scopes or smoking light cords, with 22 cases. Eighteen RCAs involved a sentinel event, including 12 retained surgical items (RSI) (surgical sponge, retained guidewire) and 6 wrong site surgeries (WSS) (incorrect laterality, wrong procedure) representing a serious safety event rate of 1 in 17,762 procedures. In addition, 8 RCAs pertained to medical or anesthesia events (incorrect dosing, postoperative myocardial infarction), 7 to pathology errors (missing or mislabeled specimen), 4 to incorrect patient information or consent, and 4 to surgical complications (hemorrhage, duodenal injury). In 2 cases there was inappropriate work up. One case caused a delay in treatment, one case had an incorrect count, and one case identified lack of credentialing. CONCLUSIONS: RCAs of patient safety adverse events occurring during urologic OR procedures highlight the need for targeted quality improvement projects to prevent WSS events, prevent RSI events, and maintain properly functioning equipment.

Development and Validation of the Veterans Health Administration Patient Safety Culture Survey.

RATIONALE, AIMS, AND OBJECTIVES: Patient safety culture (PSC) is an important concept in healthcare organization, and measuring it can lead to improved patient safety event reporting. We sought to test and validate an abbreviated version of a PSC measure within the Veterans Health Administration (VHA). METHODS: An initial set of 34 items was identified to represent the VHA Patient Safety Culture Survey (VHA-PSCS). The items were administered as part of an annual survey administration in June 2019 (N = 205,117, 66.1% response rate). We derived a split-half sample and conducted exploratory and confirmatory factor analysis to identify factors. We examined reliability along with construct and criterion validity of the VHA-PSCS in relation to other workplace attitudes and behaviors. RESULTS: The final instrument includes 20 items with 4 scales derived from factor analysis: (a) risk identification and just culture; (b) error transparency and mitigation; (c) supervisor communication and trust; and (d) team cohesion and engagement. Reliability was supported based on Cronbach α coefficients and split-half testing. For criterion validity, Spearman correlations were greater than 0.40 between VHA-PSCS scales and employee satisfaction and intrinsic work experience. Correlations were greater than 0.20 between VHA-PSC scales and intent to leave, burnout, and self-rated reporting of error incidents. CONCLUSIONS: The VHA-PSCS reflects 4 dimensions of patient safety. The instrument can be used to benchmark and compare progress of VHA's PSC transformation across the organization and within medical centers, to strengthen patient safety event reporting, investigation, and quality of care.

Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review.

OBJECTIVE: To promote a safety culture and reduce harm, health care systems are adopting high-reliability organization (HRO) principles. This rapid review synthesizes HRO frameworks, metrics, and implementation effects to help inform health systems' efforts toward becoming HROs. METHODS: Bibliographic databases were searched from 2010 to 2019. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, extract data, and grade strength of evidence with second reviewer checking. RESULTS: Twenty-three articles were identified: 8 described frameworks, 9 examined metrics, and 9 evaluated implementation outcomes. Five common strategies for HRO implementation emerged (developing leadership, supporting a culture of safety, providing training and learning, building data systems, and implementing quality improvement interventions). The Joint Commission's and Institute for Healthcare Improvement's frameworks emerged as the most comprehensive and widely applicable. The Joint Commission's Oro 2.0 metric for evaluating HRO progress similarly stood out as it was developed through broad stakeholder input and was validated by external researchers. Multicomponent HRO interventions delivered for at least 2 years were associated with improved process and patient safety outcomes. Because each HRO intervention was only supported by a single poor or fair-quality study-none of which contained a concurrent control group-a causal relationship between any HRO initiative and outcomes could not be established. CONCLUSIONS: Health care system adoption of HRO principles is associated with improved safety outcomes, yet the level of evidence is low. Priorities for future HRO studies include use of concurrent control groups and examination of specific outcomes measurements.

A High-Reliability Organization Framework for Health Care: A Multiyear Implementation Strategy and Associated Outcomes.

OBJECTIVES: Applying high-reliability organization (HRO) principles to health care is complex. No consensus exists as to an effective framework for HRO implementation or the direct impact of adoption. METHODS: The Veterans Health Administration (VHA) National Center for Patient Safety established the high-reliability hospital (HRH) model for HRO adoption and piloted HRH in collaboration with the Truman VA Medical Center (Truman) during a 3-year intervention period (January 1, 2016-December 31, 2018). High-reliability hospital components are as follows: annual patient safety (PS) assessment, annual PS culture survey, annual root cause analysis training, daily leadership walk-arounds, monthly PS forum, annual processes standardization review, Just Culture training, unit-based Clinical Team Training, unit-based continuous improvement projects, and annual Clinical Team Training simulation education. The impact of HRH was examined using a PS Culture Survey, PS event reporting, and quality outcomes of standardized mortality rate and complication rate. RESULTS: Truman internally improved PS culture and PS event reporting rates resulting in outcomes better than all VHA facilities (All VHA; P < 0.001 and P < 0.001, respectively). Low-harm PS event reporting increased (P < 0.001); however, serious safety event rate remained unchanged versus All VHA. Significant improvement in Truman standardized mortality rate and complication rate versus All VHA occurred immediately and were sustained through intervention (slopes, P < 0.001 and P < 0.020; respectively). CONCLUSIONS: High-reliability hospital is an effective framework for HRO implementation and will be applied to 18 additional VHA sites. Based on these results, the expected outcome will be improved PS culture and overall PS event reporting. The impact of HRH on serious safety event rate and quality measures requires further study.

Patient Misidentification Events in the Veterans Health Administration: A Comprehensive Review in the Context of High-Reliability Health Care.

OBJECTIVES: The Veterans Health Administration maintains national patient safety event reporting and root cause analysis (RCA) databases. These were reviewed to understand the prevalence of and provide insight into patient misidentification. The results were compared with a high-reliability health care framework. METHODS: We reviewed patient safety reports and RCA reports to identify and categorize patient identification-related events from October 1, 2016, to September 30, 2018. We analyzed 3232 patient safety reports and 67 RCAs, aggregated the findings, and compared them against The Joint Commission's High Reliability Health Care Maturity Model. RESULTS: Patient misidentification occurred in both inpatient and outpatient settings, for which the ratio of adverse events to close calls was similar. The ratio of adverse events to close calls varied for specific care areas. The most common RCA event characteristic was Two identifiers not used (39%). The most common failure mode was Procedure performed on wrong patient (31%). Issues related to policy and processes accounted for 42% of the root causes. Actions taken were primarily related to policy, process, and staff training/education (56%); these actions were rated as effective by the reporting facilities. CONCLUSIONS: Patient misidentification is prevalent in both the inpatient and outpatient settings. However, specific care areas reported more close calls, an indicator of good safety culture. There were associations between policy and process issues, consistent use of 2 identifiers, and misidentification events. This review provides insight from the Veterans Health Administration national databases that health care institutions can use to improve their systems.

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration.

OBJECTIVES: Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy. METHODS: From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff. RESULTS: Of the 281 bleeding events reviewed, 188 (67%) were unwitnessed and 54 (19%) were associated with an alteration in mental status. Most deaths (n = 11; 79%) were associated with central venous catheter access. Root cause analyses reported 83 root causes, of which 33% identified physical barriers to direct observation or an equipment issue.Action plans addressed policy/procedures (30%), training/education (20%), and changes to environment/equipment (19%). Patient Safety Advisory publication was associated with a significant increase in low-harm PS reports, from 9 to 18 per year (P = 0.001). CONCLUSIONS: Bleeding events during hemodialysis treatments occur and may be fatal. Heightened vigilance is required when physical barriers obscure continuous direct observation, the patient exhibits an altered mental status, and vascular access is through a central venous catheter.Provider staff should consider a safety checklist and training on equipment operation. Patient Safety Advisory publication was associated with increased low-harm event reporting.

Cardiac Telemetry Downtime and Contingency Plan Development: A Review of Downtime Events Reported in the Veterans Health Administration.

BACKGROUND: Cardiac telemetry downtime may be planned or unplanned, causing a disruption in telemetry services with a potential to impact patient safety. PROBLEM: Many cardiac telemetry units in the Veterans Health Administration (VHA) have contingency plans that do not adequately address telemetry downtime. APPROACH: This is a retrospective quality improvement analysis of VHA-reported cardiac telemetry downtime events from October 1, 2014, to Mar 31, 2020. OUTCOMES: Of 98 events, no patient harm was reported; 13% (n = 13) were planned downtime, 82% (n = 80) were unplanned downtime, 18% (n = 18) reported contingency plan use, 78% (n = 76) did not specify contingency plan use, and 32% (n = 31) reported events lasting 31 minutes to 6 hours in duration. CONCLUSIONS: The majority of reported cardiac telemetry downtime events were unplanned and without documented contingency plans. A robust contingency plan with defined staff roles and responsibilities will serve to lessen anxiety during downtimes and mitigate potential risk of patient harm.

Suicide and Suicide Attempts on Veterans Affairs Medical Center Outpatient Clinic Areas, Common Areas, and Hospital Grounds.

OBJECTIVES: Few studies have analyzed suicide deaths and attempts occurring outside inpatient units on other hospital locations. We aimed to quantify and analyze suicide deaths and attempts occurring on Department of Veterans Affairs medical center outpatient clinic areas, common areas, and hospital grounds including parking lots to determine whether a relationship with access to mental health care exists and to elucidate potential mitigation strategies. METHODS: We conducted a retrospective review of patient safety report (n = 3,186), root cause analysis (n = 234), and issue brief (n = 2,064) national databases between January 1, 2015, and December 31, 2018, to identify occurrences of suicides and attempts. Correlation between mental health access times and hospital-specific rates of suicides and attempts was assessed. Qualitative analyses of root causes and mitigation strategies were conducted. RESULTS: Of 192 reports meeting our location criteria, 42 suicides or attempts occurred in outpatient clinic areas, 39 in common spaces, and 111 on outdoor facility areas. Forty-four reports (23%) pertained to suicides, and 148 (77%) pertained to attempts. The predominate methods were death by firearms (64%) and attempt by drug overdose (38%). We identified a weak yet significant relationship between mental health access times for established patients and rates of on-campus suicides and attempts (r = 0.279, P = 0.0013). CONCLUSIONS: Clinical changes including environmental assessments and interventions, staff training on identifying suicide risk characteristics, policy changes toward improving contraband search techniques, and medications risk assessment, as well as timely access to care may be effective mitigation strategies toward preventing suicides of this nature.

Clinical outcomes and cost of robotic ventral hernia repair: systematic review.

BACKGROUND: Robotic ventral hernia repair (VHR) has seen rapid adoption, but with limited data assessing clinical outcome or cost. This systematic review compared robotic VHR with laparoscopic and open approaches. METHODS: This systematic review was undertaken in accordance with PRISMA guidelines. PubMed, MEDLINE, Embase, and Cochrane databases were searched for articles with terms relating to 'robot-assisted', 'cost effectiveness', and 'ventral hernia' or 'incisional hernia' from 1 January 2010 to 10 November 2020. Intraoperative and postoperative outcomes, pain, recurrence, and cost data were extracted for narrative analysis. RESULTS: Of 25 studies that met the inclusion criteria, three were RCTs and 22 observational studies. Robotic VHR was associated with a longer duration of operation than open and laparoscopic repairs, but with fewer transfusions, shorter hospital stay, and lower complication rates than open repair. Robotic VHR was more expensive than laparoscopic repair, but not significantly different from open surgery in terms of cost. There were no significant differences in rates of intraoperative complication, conversion to open surgery, surgical-site infection, readmission, mortality, pain, or recurrence between the three approaches. CONCLUSION: Robotic VHR was associated with a longer duration of operation, fewer transfusions, a shorter hospital stay, and fewer complications compared with open surgery. Robotic VHR had higher costs and a longer operating time than laparoscopic repair. Randomized or matched data with standardized reporting, long-term outcomes, and cost-effectiveness analyses are still required to weigh the clinical benefits against the cost of robotic VHR.

Veterans Health Administration Scheduling System: The Path to High Reliability Realization.

EXECUTIVE SUMMARY: Timely access to services is the gateway to patient safety and quality, and scheduling is foundational to providing access to highly reliable care. An effective and efficient scheduling strategy is dependent on an evidence-based approach that focuses on critical drivers of the scheduling system related to patient safety and quality as well as access. As part of a continuing effort to improve access, the Veterans Health Administration (VHA) completed a direct causation analysis (2015-2020) using an evidence-based framework and comprehensive measurement plan. The analysis, described here, validates access benefits realized specialty by specialty and facility by facility, identifies opportunities for improvement, and acknowledges limitations of the change from the Veterans Information Systems and Technology Architecture scheduling system to the Medical Appointment Scheduling System.This analysis of the assessments illustrates business validation structures, drivers, processes, and outcomes that can support leadership decision-making related to access. We drew our assessments of people, processes, policies, and technology from on-site interviews, over-the-shoulder observations, large-group discussions, and data from the VHA Support Service Center and facility data systems; we also mapped process steps, keystrokes, and workflow. Our assessments provided support for the VHA's decision to implement the stand-alone Cerner scheduling system at one site while continuing to implement the Cerner Millennium electronic health record platform that includes the Cerner scheduling system at other VHA sites. The VHA experience provides lessons learned for healthcare leaders who seek highly reliable efforts to improve access to care.

Comparison of Clinical Outcomes of Robot-Assisted, Video-Assisted, and Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis.

Importance: The utilization of robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer is increasing, despite limited data comparing RAMIE with other surgical approaches. Objective: To evaluate the literature for clinical outcomes of RAMIE compared with video-assisted minimally invasive esophagectomy (VAMIE) and open esophagectomy (OE). Data Sources: A systematic search of PubMed, Cochrane, Ovid Medline, and Embase databases from January 1, 2013, to May 6, 2020, was performed. Study Selection: Studies that compared RAMIE with VAMIE and/or OE for cancer were included. Data Extraction and Synthesis: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, data were extracted by independent reviewers. A random-effects meta-analysis of 9 propensity-matched studies was performed for the RAMIE vs VAMIE comparison only. A narrative synthesis of RAMIE vs VAMIE and OE was performed. Main Outcomes and Measures: The outcomes of interest were intraoperative outcomes (ie, estimated blood loss [EBL], operative time, lymph node [LN] harvest), short-term outcomes (anastomotic leak, recurrent laryngeal nerve [RLN] palsy, pulmonary and total complications, and 90-day mortality), and long-term oncologic outcomes. Results: Overall, 21 studies (2 randomized clinical trials, 11 propensity-matched studies, and 8 unmatched studies) with 9355 patients were included. A meta-analysis was performed with 9 propensity-matched studies comparing RAMIE with VAMIE. The random-effects pooled estimate found an adjusted risk difference (RD) of -0.06 (95% CI, -0.11 to -0.01) favoring fewer pulmonary complications with RAMIE. There was no evidence of differences between RAMIE and VAMIE in LN harvest (mean difference [MD], -1.1 LN; 95% CI, -2.45 to 0.25 LNs), anastomotic leak (RD, 0.0; 95% CI, -0.03 to 0.03), EBL (MD, -6.25 mL; 95% CI, -18.26 to 5.77 mL), RLN palsy (RD, 0.01; 95% CI, -0.08 to 0.10), total complications (RD, 0.05; 95% CI, -0.01 to 0.11), or 90-day mortality (RD, -0.01; 95% CI, -0.02 to 0.0). There was low certainty of evidence that RAMIE was associated with a longer disease-free survival compared with VAMIE. For OE comparisons (data not pooled), RAMIE was associated with a longer operative time, decreased EBL, and less pulmonary and total complications. Conclusions and Relevance: In this study, RAMIE had similar outcomes as VAMIE but was associated with fewer pulmonary complications compared with VAMIE and OE. Studies on long-term functional and cancer outcomes are needed.

Review of Reported Adverse Events Occurring Among the Homeless Veteran Population in the Veterans Health Administration.

BACKGROUND: United States veterans face an even greater risk of homelessness and associated medical conditions, mental health conditions, and fatal and nonfatal overdose as compared with nonveterans. Beginning 2009, the Department of Veterans Affairs developed a strategy and allocated considerable resources to address veteran homelessness and the medical conditions commonly associated with this condition. OBJECTIVE: This study aimed to examine the Veterans Health Administration National Center for Patient Safety database for patient safety events in the homeless veteran population to mitigate future risk and inform policy. METHODS: This was a retrospective, descriptive quality improvement study of reported patient safety events of homeless veterans enrolled in Veterans Health Administration care between January 2012 and August 2020. A validated codebook was used to capture individual patient characteristics, location and type of event, homeless status, and root causes of the events and proposed actions for prevention. RESULTS: Suicide attempt or death, elopement, delay in care, and unintentional opioid overdose were the most common adverse events reported for this population. Root causes include issues with policies, procedures, and care processes for managing and evaluating homeless patients for the risk of suicidal or overdose behaviors and discharge, poor interdisciplinary communication, and coordination of patient care. Actions included standardization of procedures for discharge, overdose and suicide risk, staff education, and purchasing new equipment. CONCLUSIONS: Suicide and opioid overdose are the most serious reported health care-related adverse events in the unsheltered homeless veteran population. Failures to recognize homelessness status, communicate status, and coordinate available services are root causes of these events.

Root Cause Analysis of Adverse Events Involving Opioid Overdoses in the Veterans Health Administration.

OBJECTIVE: The Veterans Health Administration (VHA) serves a population with compounding risk factors for opioid misuse, including chronic pain, substance use disorders, and mental health conditions. The objective of this study was to analyze opioid-related adverse events and root causes to inform mitigation strategies associated with opioid prescribing and administration. METHODS: The researchers conducted a retrospective analysis of root cause analysis reports of opioid overdose events between August 1, 2012, and September 30, 2019. These adverse events were investigated locally by multidisciplinary hospital teams and reported by VHA facility patient safety managers to the National Center for Patient Safety for further aggregation and analysis. Type of event, location, and root causes were categorized. RESULTS: Eighty-two adverse event reports were identified. Patients were primarily male with an average age of 61.4 years. Staff medication administration errors were the most common event type (57.3%), with most events resulting from process errors (65.9%) occurring in the health care setting (85.4%). Overall 36 events (43.9%) resulted in major or catastrophic harm. There were 172 root causes identified. The most common root causes were staff not following existing policy or lack of existing hospital policy on opioid management (18.0%); staff lacked training in areas such as managing the use or administration of opioids, correct use of opioid dispensing equipment, and recognition and proper response to an overdose (12.2%); and poor communication of opioid prescribing or administration during handoffs between clinical teams (11.6%). A lack of standardization in processes, training, and policies on opioid prescribing and screening, medication administration, equipment/pumps purchase and use, and contraband searches was a common theme throughout. CONCLUSION: Errors in prescribing and administration of opioid medication can result in significant harm. A lack of standardized opioid administration practices and training, controlled substance policies, and interdisciplinary communication were frequent factors in adverse opioid events and should be a focus for future prevention.

Intraoperative and postoperative outcomes of robot-assisted cholecystectomy: a systematic review.

BACKGROUND: Rapid adoption of robotic-assisted general surgery procedures, particularly for cholecystectomy, continues while questions remain about its benefits and utility. The objective of this study was to compare the clinical effectiveness of robot-assisted cholecystectomy for benign gallbladder disease as compared with the laparoscopic approach. METHODS: A literature search was performed from January 2010 to March 2020, and a narrative analysis was performed as studies were heterogeneous. RESULTS: Of 887 articles screened, 44 met the inclusion criteria (range 20-735,537 patients). Four were randomized controlled trials, and four used propensity-matching. There were variable comparisons between operative techniques with only 19 out of 44 studies comparing techniques using the same number of ports. Operating room time was longer for the robot-assisted technique in the majority of studies (range 11-55 min for 22 studies, p < 0.05; 15 studies showed no difference; two studies showed shorter laparoscopic times), while conversion rates and intraoperative complications were not different. No differences were detected for the length of stay, surgical site infection, or readmissions. Across studies comparing single-port robot-assisted to multi-port laparoscopic cholecystectomy, there was a higher rate of incisional hernia; however, no differences were noted when comparing single-port robot-assisted to single-port laparoscopic cholecystectomy. CONCLUSIONS: Clinical outcomes were similar for benign, elective gallbladder disease for robot-assisted compared with laparoscopic cholecystectomy. Overall, the rates of complications were low. More high-quality studies are needed as the robot-assisted technique expands to more complex gallbladder disease, where its utility may prove increasingly beneficial. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020156945.

Power Failures During Surgery: A 2000-2019 Review of Reported Events in the Veterans Health Administration.

OBJECTIVES: The frequency and impact of power failure on surgical care over time in a large integrated healthcare system such as the Veterans Health Administration (VHA) is unknown. Reducing the likelihood of harm related to these rare but potential catastrophic events is imperative to ensuring patient safety and high-quality surgical care. This study provides analysis and description of reported power failures during surgery (January 2000-March 2019), in the VHA and their impact. METHODS: This quality improvement study describes patient safety adverse events related to power failure in the operating room reported by 63 VHA medical centers from the approximately 137 VHAs with a surgical program. Power failure events during surgery reported to the VHA National Center for Patient Safety are analyzed. RESULTS: The authors identify 20 root cause analyses and 135 safety reports. Most events 36.1% (n = 56) resulted from generator delay, equipment reboot delay 21.9% (n = 34), and equipment backup power failure 13.5% (n = 21). Root causes include issues with backup batteries or equipment, engineering and clinical staff communication, standardized procedures for testing power, backup power delay, electrical circuit issues, documentation, and training. Patient harm occurred in 18% (n = 28) and 3.9% (n = 6) as major or catastrophic. CONCLUSIONS: Power failure during surgery is associated with major or catastrophic patient harm, though rare. Staff preoccupation with failure, disaster preparedness, and focus on communication has the potential to minimize or avoid patient harm.

Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare.

BACKGROUND AND OBJECTIVES: Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation. RESULTS: Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non-Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1). CONCLUSIONS: Most dually enrolled veterans underwent transplantation at a non-Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration-only post-transplant care had the lowest 5-year mortality.

Perioperative and Long-Term Outcomes of Robot-Assisted Partial Nephrectomy: A Systematic Review.

BACKGROUND: Adoption of the robotic surgical platform for small renal cancers has rapidly expanded, but its utility compared to other approaches has not been established. The objective of this review is to assess perioperative and long-term oncologic and functional outcomes of robot-assisted partial nephrectomy (RAPN) compared to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN). METHODS: A search in PubMed, Embase, and Cochrane (2010-2019) was conducted. Of 3877 articles screened, 7 observational studies were included. RESULTS: RAPN was associated with 24-50 mL less intraoperative blood loss compared to LPN and 39-84 mL less than OPN. RAPN also demonstrated trends of other postoperative benefits, such as shorter length of stay and fewer major complications. Several studies reported better long-term functional kidney outcomes, but these findings were inconsistent. Recurrence and cancer-specific survival (CSS) were similar across groups. While RAPN had a 5-year CSS of 90.1%-97.9%, LPN and OPN had survival rates of 85.9%-86.9% and 88.5-96.3% respectively. CONCLUSIONS: RAPN may be associated with a lower estimated blood loss and comparable long-term outcomes when compared to other surgical approaches. However, additional randomized or propensity matched studies are warranted to fully assess long-term functional kidney and oncologic outcomes.

Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units.

INTRODUCTION: Suicide is the 10th leading cause of death in the USA. Inpatient suicide is the fourth most common sentinel event reported to the Joint Commission. This study reviewed root cause analysis (RCA) reports of suicide events by hospital unit to provide suicide prevention recommendations for each area. METHODS: This is a retrospective analysis of reported suicide deaths and attempts in the US Veterans Health Administration (VHA) hospitals. We searched the VHA National Center for Patient Safety RCA database for suicide deaths and attempts on inpatient units, outpatient clinics and hospital grounds, between December 1999 and December 2018. RESULTS: We found 847 RCA reports of suicide attempts (n=758) and deaths (n=89) in VHA hospitals, hanging accounted for 71% of deaths on mental health units and 50% of deaths on medical units. Overdose accounted for 55% of deaths and 68% of attempts in residential units and the only method resulting in death in emergency departments. In VHA community living centres, hanging, overdose and asphyxiation accounted for 64% of deaths. Gunshot accounted for 59% of deaths on hospital grounds and 100% of deaths in clinic areas. All inpatient locations cited issues in assessment and treatment of suicidal patients and environmental risk evaluation. CONCLUSIONS: Inpatient mental health and medical units should remove anchor points for hanging where possible. On residential units and emergency departments, assessing suicide risk, conducting thorough contraband searches and maintaining observation of suicidal patients is critical. In community living centres, suicidal patients should be under supervision in an environment free of anchor points, medications and means of asphyxiation. Suicide prevention on hospital grounds and outpatient clinics can be achieved through the control of firearms.

The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration.

OBJECTIVES: The aim of the study was to compare retained surgical item (RSI) rates for 137 Veterans Health Administration Surgery Programs with and without surgical count technology and the root cause analysis (RCA) for soft good RSI events between October 1, 2009 and December 31, 2016. A 2017 survey identified 46 programs to have independently acquired surgical count technology. METHODS: Retained surgical item rates were calculated by the sum of events (sharp, soft good, instrument) divided by the total procedures performed. The RCAs for RSI events were analyzed using codebooks for procedure type/location and root cause characterization. RESULTS: One hundred twenty-four RSI events occurred in 2,964,472 procedures for an overall RSI rate of 1/23,908 procedures. The RSI rates for 46 programs with surgical count technology were significantly higher in comparison with 91 programs without a surgical count technology system (1/18,221 versus 1/30,593, P = 0.0026). The RSI rates before and after acquiring the surgical count technology were not significantly different (1/17,508 versus 1/18,673, P = 0.8015). Root cause analyses for 42 soft good RSI events identified multiple associated disciplines (general surgery 26, urology 5, cardiac 4, neurosurgery 3, vascular 2, thoracic 1, gynecology 1) and locations (abdomen 26, thorax 7, retroperitoneal 4, paraspinal 2, extremity 1, pelvis 1, and head/neck 1). Human factors (n = 24), failure of policy/procedure (n = 21), and communication (n = 19) accounted for 64 (65%) of the 98 root causes identified. CONCLUSIONS: Acquisition of surgical count technology did not significantly improve RSI rates. Soft good RSI events are associated with multiple disciplines and locations and the following dominant root causes: human factors, failure to follow policy/procedure, and communication.