The study looked at patient safety adverse events and close calls for adverse events reported from 86 VHA medical centers. Researchers analyzed surgical procedures that took place between January 1, 2010, and December 31, 2017.
Categories of incorrect procedure types analyzed in the study were wrong patient, wrong side, wrong site, wrong procedure or wrong implant. Events included those in or outside the OR, adverse events or close calls, surgical specialty and harm. The researchers compared these results with previous studies of VHA-reported wrong-site surgery.
The review produced 483 reports (277 adverse events and 206 close calls). The rate of in-OR reported adverse events with harm has continued to drop, the researchers found.
“[VHA] organizational efforts continue to … enhance policy to promote a culture and behavior that minimizes events and is transparent in reporting occurrences,” the researchers concluded.
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