Adverse events in orthopedic surgery persist despite directives to correct them

Orthopedic and ophthalmic surgical procedures performed inside and outside an operating room were commonly associated with adverse events compared to other types of surgery performed at Veterans Health Administration Medical Centers from 2001 to mid-2006, investigators found.

Julia Neily, RN, MS, MPH, of Veterans Health Administration (VHA), White River Junction, Vt., and colleagues identified communication problems as the most common root cause of these adverse events. Communication mishaps occurred in conjunction with 21% of the adverse events noted in their study, which appears in the November issue of Archives of Surgery.

Since programs to prevent surgical errors are being implemented at the international, national and VHA level to prevent surgical errors, the researchers sought to describe which incorrect procedures were being performed and to provide some solutions.

“For orthopedics, the event was often the unpleasant surprise that the desired-size implant was not available in the operating room or elsewhere in the hospital,” Neily and colleagues wrote in their study.

Reports reviewed

In April 2002, the VHA developed and implemented a pilot program to reduce the risk of incorrect surgical events, which resulted in dissemination of a national directive in January 2003. That rule was updated in 2004, the investigators wrote.

Neily and colleagues reviewed the surgical adverse events and incident or safety reports between January 1, 2001 and June 30, 2006 in the VHA National Center for Patient Safety database for the 130 major VHA facilities where surgical services are performed in an operating room (OR), among 153 major VHA facilities nationwide.

They then reviewed safety-related events that occurred outside the OR at all 153 major facilities.

From the reports, researchers identified 342 events, including 212 adverse events and 130 close calls. They defined an adverse event as a surgical procedure performed unnecessarily and a close call as a situation where steps that could lead to an adverse event were taken, but the patient was not subjected to the unnecessary procedure.

Orthopedic events

Investigators found a nearly equal number of adverse events occurred in the OR vs. outside the OR.

“When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2%] each), whereas orthopedics was second to ophthalmology for number of reported adverse events occurring the OR,” they wrote.

Neily and colleagues concluded that recommended time-out procedures may take place too late to adequately prevent incorrect surgeries or other problems from occurring.

“We advocate earlier improved communication based on crew resource management principles … We will continue to promote early and effective communication to prevent surgical and invasive adverse events,” they wrote.

Reference:
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-1034.