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.

Assessment of Incorrect Surgical Procedures Within and Outside the Operating Room: A Follow-up Study From US Veterans Health Administration Medical Centers.

Importance: Reducing wrong-site surgery is fundamental to safe, high-quality care. This is a follow-up study examining 8 years of reported surgical adverse events and root causes in the nation's largest integrated health care system. Objectives: To provide a follow-up description of incorrect surgical procedures reported from 2010 to 2017 from US Veterans Health Administration (VHA) medical centers, compared with the previous studies of 2001 to 2006 and 2006 to 2009, and to recommend actions for future prevention of such events. Design, Setting, and Participants: This quality improvement study describes patient safety adverse events and close calls reported from 86 VHA medical centers from the approximately 130 VHA facilities with a surgical program. The surgical procedures and programs vary in size and complexity from small rural centers to large, complex urban facilities. Procedures occurring between January 1, 2010, and December 31, 2017, were included. Data analysis took place in 2018. Main Outcomes and Measures: The categories of incorrect procedure types were wrong patient, side, site (including wrong-level spine), procedure, or implant. Events included those in or out of the operating room, adverse events or close calls, surgical specialty, and harm. These results were compared with the previous studies of VHA-reported wrong-site surgery (2001-2006 and 2006-2009). Results: Our review produced 483 reports (277 adverse events and 206 close calls). The rate of in-operating room (in-OR) reported adverse events with harm has continued to trend downward from 1.74 to 0.47 reported adverse events with harm per 100 000 procedures between 2000 and 2017 based on 6 591 986 in-OR procedures. When in-OR events were examined by discipline as a rate, dentistry had 1.54, neurosurgery had 1.53, and ophthalmology had 1.06 reported in-OR adverse events per 10 000 cases. The overall VHA in-OR rate for adverse events during 2010 to 2017 was 0.53 per 10 000 procedures based on 3 234 514 in-OR procedures. The most common root cause for adverse events was related to issues in performing a comprehensive time-out (28.4%). In these cases, the time-out either was conducted incorrectly or was incomplete in some way. Conclusions and Relevance: Over the period studied, the VHA identified a decrease in the rate of reported adverse events in the OR associated with harm and continued reporting of adverse event close calls. Organizational efforts continue to examine root cause analysis reports, promulgate lessons learned, and enhance policy to promote a culture and behavior that minimizes events and is transparent in reporting occurrences.

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.