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.

Implementing Evidence-Based Pressure Injury Prevention Interventions: Veterans Health Administration Quality Improvement Collaborative.

BACKGROUND: Pressure injury prevention is a persistent concern in nursing. The Veterans Health Administration implemented a creative approach with successful outcomes across the United States. PROBLEM: Pressure injury prevention is a measure of nursing quality of care and a high priority in the Veterans Health Administration. METHODS: A 12-month Virtual Breakthrough Series Collaborative utilizing coaching and group calls was conducted to assist long-term and acute care teams with preventing pressure injuries. INTERVENTIONS: Interventions from the Veterans Health Administration Skin Bundle were implemented, including pressure-relieving surfaces, novel turning techniques, specialized dressings, and emollients to prevent skin breakdown. RESULTS: The aggregated pressure injury rate for all teams decreased from Prework to the Action phase from 1.0 to 0.8 per 1000 bed days of care (P = .01). The aggregated pressure injury rates for long-term care units decreased from Prework to Continuous Improvement from 0.8 to 0.4 per 1000 bed days of care (P = .021). CONCLUSION: The Virtual Breakthrough Series helped reduce pressure injuries.

Genome Editing and Human Reproduction: The Therapeutic Fallacy and the "Most Unusual Case".

In the current agon between those promoting and opposing the development of human reproductive applications of genome editing techniques, the bone of contention is often whether the prospective reproductive technologies answer an "unmet medical need." Proponents often point to highly unusual cases of inherited genetic conditions as exhibiting that need. This essay argues that we ought to admit that the opponents are correct: human reproductive genome editing cannot be justified on medical grounds. Taking a deliberately provocative line, the essay suggests how inscribing such practices within a conventional model of biomedical research fails to take proper account of the interrelated interests in play, including those of the wider society and its future members. It also obscures important questions about how the public significance and value of human genome editing are produced through the dynamic encounter between science, technology, and social morality. This has certain discomfiting implications that will require both courage and humility to confront and-finally, perhaps-to embrace.

Recommendations for Fall-Related Injury Prevention: A 1-Year Review of Fall-Related Root Cause Analyses in the Veterans Health Administration.

BACKGROUND: Injurious falls continue to challenge health care. Causes of serious falls from the largest health care system in the United States can direct future prevention efforts. PURPOSE: This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events. METHODS: We categorized root cause analysis (RCA) reports and coded injury type, fall type, location, and root causes. We describe interventions during the fall and provide resources for future prevention. RESULTS: There were 154 reported fall RCAs during this time. Most (83%, n = 128) resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116). CONCLUSIONS: Patients who fell were not wearing hip or head protection. Most falls were unwitnessed, and none were on 1:1 observation. Such interventions may help prevent future injurious falls.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units?

BACKGROUND: Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting. METHODS: The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient. These safety events were then matched to incidents that were reported to the VHA Adverse Event Reporting System (AERS), which includes all reported adverse events, close calls, and root cause analyses that occur within the VHA health system. RESULTS: Overall, 37.4% (95% confidence interval [CI] = 33.5%-41.5%) of safety events detected in the medical record were reported to the AERS. Among the patient safety events identified, the most commonly reported to the AERS were patient falls (52.3%), assaults (46.2%), and elopements (42.3%). Reporting rates increased when the patient safety event resulted in harm to the patient (48.2%; CI = 41.6%-55.0%). CONCLUSION: The majority of patient safety events that occur on VHA inpatient psychiatric units do not get reported to the VHA's Adverse Event Reporting System. These findings suggest that self-reporting is not a reliable method of tracking patient safety events. Future efforts should target the barriers to inpatient psychiatric reporting and develop mechanisms to overcome these barriers.

How to do a Virtual Breakthrough Series Collaborative.

Despite widespread use of the breakthrough series (BTS) collaborative in healthcare, there is limited literature on how to operationalize the method in healthcare settings. A recent modification to the model is the virtual breakthrough series (VBTS), in which all work is done remotely via telephone and web-based platforms. With virtual methods gaining popularity, this manuscript presents guidance on methods to conduct a virtual breakthrough series collaborative to assist clinical teams in implementing evidence-based practices. Manuscript describes planning activities and implementation steps for individuals interested in conducting a VBTS collaborative. Topics presented include planning/preparation activities (e.g., developing a planning committee and change package of the evidence-based interventions), estimated resources required (i.e., personnel, percent effort), activities to prepare participants for the project (e.g., orientation calls), specific actions during the virtual collaborative, and evaluation approaches. The manuscript also presents examples from our work and templates for end users. This paper is a first attempt to describe the infrastructure and processes of a VBTS collaborative and offer reproducible methods currently employed in the U.S. Veterans Health Administration.

Factors contributing to cancer-related suicide: A study of root-cause analysis reports.

OBJECTIVE: Vast efforts are directed toward curing or prolonging the life of patients with cancer. However, less attention is given to mental health aspects of cancer care, and there is elevated incidence of death by suicide in this population. Evaluating Root Cause Analyses (RCAs) of cancer-related suicides may further our understanding of system-level factors that may contribute to suicide in patients with cancer and highlight strategies to mitigate this risk. METHODS: We searched the Veterans Health Administration National Center for Patient Safety RCA database for cancer-related suicides between 2002 and 2017 to evaluate the context of the suicides and identify root causes and suggested actions. These variables were coded by consensus and evaluated using descriptive statistics. RESULTS: We identified 64 RCA reports involving cancer-related suicide; 100% were males of older age. Many suicides occurred during treatment with palliative intent (44%, N = 28). Depression (59%, N = 38), medical comorbidities (59%, N = 38), and pain (47%, N = 30) were common suicide risk factors identified. Most suicides occurred within 7 days of a medical visit (67%, N = 43), especially within the first 24 hours (41%, N = 26). Root causes included a need to improve recognition of triggers for assessment and interdisciplinary communication. CONCLUSION: This analysis uncovers opportunities to mitigate risk of death by suicide among patients with cancer. Suggested actions include use of comprehensive cancer centers and development of a distress checklist using information from the National Comprehensive Cancer Network Guidelines. Further studies should assess additional factors that may increase the risk of other adverse mental health outcomes in this population.

Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned.

BACKGROUND: Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions. METHODS: RCA reports from VHA hospitals from May 30, 2012, to May 1, 2015, were reviewed for root causes, severity of patient outcomes, and actions. These elements were coded by consensus and analyzed using descriptive statistics. RESULTS: During the study period, 3228 RCAs were submitted, of which 292 involved an anesthesia provider. Thirty-six of these were specific to anesthesia care. We reviewed these 36 RCA reports of adverse events specific to anesthesia care. Types of event included medication errors (28%, 10), regional blocks (14%, 5), airway management (14%, 5), skin integrity or position (11%, 4), other (11%, 4), consent issues (8%, 3), equipment (8%, 3), and intravenous access and anesthesia awareness (3%, 1 each). Of the 36 anesthesia events reported, 5 (14%) were identified as being catastrophic, 10 (28%) major, 12 (34%) moderate, and 9 (26%) minor. The majority of root causes identified a need for improved standardization of processes. CONCLUSIONS: This analysis points to the need for systemwide implementation of human factors engineering-based approaches to work toward further eliminating anesthesia-related adverse events. Such actions include standardization of processes, forcing functions, separating storage of look-alike sound-alike medications, limiting stock of high-risk medication strengths, bar coding medications, use of cognitive aids such as checklists, and high-fidelity simulation.

Preventing Falls and Fall-Related Injuries in State Veterans Homes: Virtual Breakthrough Series Collaborative.

This article reports on improved processes and outcomes from a virtual breakthrough series quality improvement collaborative to reduce preventable falls and fall-related injuries in 23 State Veterans Homes. Participating teams implemented 24 interventions (process changes); the most common was the postfall huddle. Teams reduced falls and fall-related injuries. This project highlights the importance of leadership support, interdisciplinary team involvement, and collaboration as essential components of fall prevention work.

Impact of The Daily Plan on Length of Stay and Readmission.

The Veterans Health Administration implemented The Daily Plan (TDP) to improve patient safety. We compared length of stay and readmission between intervention and control units. Length of stay decreased for both groups. Readmission rates increased for controls (21.3%-25.0%, P = .02) and barely changed for TDP units (21.7%-22.5%, P = .37). Although there were no efficiency improvements, TDP's ultimate goal was safety. Not all patient safety actions improve efficiency; nonetheless, their value continues.