Featured Research

from universities, journals, and other organizations

Surgical errors remain a challenge in and out of the operating room

Date:
November 17, 2009
Source:
JAMA and Archives Journals
Summary:
Despite a national focus on reducing surgical errors, surgery-related adverse events continue to occur both inside and outside the operating room, according to an analysis of events at Veterans Health Administration Medical Centers.

Despite a national focus on reducing surgical errors, surgery-related adverse events continue to occur both inside and outside the operating room, according to an analysis of events at Veterans Health Administration Medical Centers published in the November issue of Archives of Surgery, one of the JAMA/Archives journals.

Related Articles


An estimated five to 10 incorrect surgical procedures occur daily in the United States, some with devastating effects, according to background information in the article. Surgery can be performed on the wrong site, wrong side of the body, using an incorrect procedure or on the wrong patient. "The Veterans Health Administration developed and implemented a pilot program to reduce the risk of incorrect surgical events in April 2002, which resulted in the dissemination of a national directive in January 2003," the authors write. The rule was further updated in 2004.

Julia Neily, R.N., M.S., M.P.H., of Veterans Health Administration (VHA), White River Junction, Vt., and colleagues reviewed reported surgical adverse events occurring at 130 VHA facilities between January 2001 and June 2006. Events were categorized by location (inside the operating room vs. outside, at a location such as a procedure room at a clinic or at the patient's bedside), specialty departments, body segments, severity and several other characteristics.

Overall, the researchers reviewed 342 reported events, including 212 adverse events (any surgical procedure performed unnecessarily, such as a procedure performed on the wrong patient or wrong site) and 130 close calls (in which a recognizable step toward an adverse event occurred but the patient was not subjected to the unnecessary procedure). Of the adverse events, 108 (50.9 percent) occurred in an operating room and 104 (49.1 percent) occurred elsewhere.

"When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2 percent] each), whereas orthopedics was second to ophthalmology for the number of reported adverse events occurring in the operating room," the authors write. "Pulmonary medicine cases (such as wrong-side thoracentesis [removing fluid from chest]) and wrong-site cases (such as wrong spinal level) were associated with the most harm. The most common root cause of events was communication (21.0 percent)."

The results indicate that communication problems often occur early in surgical procedures, and interventions such as a final "time-out" moments before incision may occur too late to correct them. "Incorrect surgical procedures are not only an operating room challenge but also a challenge for events occurring outside of the operating room," the authors conclude. "We support earlier communication based on crew resource management to prevent surgical adverse events."

This material is the result of work supported with resources and the use of facilities at the Department of Veterans Affairs National Center for Patient Safety at Ann Arbor, Mich., and the Veterans Affairs Medical Center, White River Junction, Vt., and the Department of Veterans Affairs Central Office, Washington, DC.


Story Source:

The above story is based on materials provided by JAMA and Archives Journals. Note: Materials may be edited for content and length.


Journal Reference:

  1. Neily et al. Incorrect Surgical Procedures Within and Outside of the Operating Room. Archives of Surgery, 2009; 144 (11): 1028 DOI: 10.1001/archsurg.2009.126

Cite This Page:

JAMA and Archives Journals. "Surgical errors remain a challenge in and out of the operating room." ScienceDaily. ScienceDaily, 17 November 2009. <www.sciencedaily.com/releases/2009/11/091116163218.htm>.
JAMA and Archives Journals. (2009, November 17). Surgical errors remain a challenge in and out of the operating room. ScienceDaily. Retrieved October 24, 2014 from www.sciencedaily.com/releases/2009/11/091116163218.htm
JAMA and Archives Journals. "Surgical errors remain a challenge in and out of the operating room." ScienceDaily. www.sciencedaily.com/releases/2009/11/091116163218.htm (accessed October 24, 2014).

Share This



More Health & Medicine News

Friday, October 24, 2014

Featured Research

from universities, journals, and other organizations


Featured Videos

from AP, Reuters, AFP, and other news services

Breakfast Debate: To Eat Or Not To Eat?

Breakfast Debate: To Eat Or Not To Eat?

Newsy (Oct. 23, 2014) Conflicting studies published in the same week re-ignited the debate over whether we should be eating breakfast. Video provided by Newsy
Powered by NewsLook.com
Ebola Fears Keep Guinea Hospitals Empty

Ebola Fears Keep Guinea Hospitals Empty

AP (Oct. 23, 2014) Fears of Ebola are keeping doctors and patients alike away from hospitals in the West African nation of Guinea. (Oct. 23) Video provided by AP
Powered by NewsLook.com
Despite Rising Death Toll, Many Survive Ebola

Despite Rising Death Toll, Many Survive Ebola

AP (Oct. 23, 2014) The family of a Dallas nurse infected with Ebola in the US says doctors can no longer detect the virus in her. Despite the mounting death toll in West Africa, there are survivors there too. (Oct. 23) Video provided by AP
Powered by NewsLook.com
Orthodontist Mom Jennifer Salzer on the Best Time for Braces

Orthodontist Mom Jennifer Salzer on the Best Time for Braces

Working Mother (Oct. 22, 2014) Is your child ready? Video provided by Working Mother
Powered by NewsLook.com

Search ScienceDaily

Number of stories in archives: 140,361

Find with keyword(s):
Enter a keyword or phrase to search ScienceDaily for related topics and research stories.

Save/Print:
Share:

Breaking News:

Strange & Offbeat Stories


Health & Medicine

Mind & Brain

Living & Well

In Other News

... from NewsDaily.com

Science News

Health News

Environment News

Technology News



Save/Print:
Share:

Free Subscriptions


Get the latest science news with ScienceDaily's free email newsletters, updated daily and weekly. Or view hourly updated newsfeeds in your RSS reader:

Get Social & Mobile


Keep up to date with the latest news from ScienceDaily via social networks and mobile apps:

Have Feedback?


Tell us what you think of ScienceDaily -- we welcome both positive and negative comments. Have any problems using the site? Questions?
Mobile: iPhone Android Web
Follow: Facebook Twitter Google+
Subscribe: RSS Feeds Email Newsletters
Latest Headlines Health & Medicine Mind & Brain Space & Time Matter & Energy Computers & Math Plants & Animals Earth & Climate Fossils & Ruins