The researchers identified 101 adverse events and 136 close calls that occurred between July 2006 and December 2009. Roughly half of the adverse events took place in the operating room, but their severity, on average, decreased. A significant decrease in the number of adverse events per month was reported (2.4 in this study vs. 3.21 in the previous study), though close calls increased from 1.97 reports per month to 3.24. The authors determined that the most common root cause of the adverse events was lack of standardization of clinical processes.
Read the news release about adverse events at VA medical centers.
Related Articles on Adverse Events:
Building a Culture of Safety: 7 Lessons From a Hospital CEO
South Carolina Hospitals Commit to Implement Surgical Safety Checklist by 2014
Pennsylvania Dept. of Health: Lehigh Valley Patient Died From Fatal Medication Error
