Research reports from the Veterans Health Administration (VHA) suggest that surgeons are affected by hearing tales of wrong-site errors and the lessons learned, but that adherence to the Universal Protocol does not prevent the errors.
The researchers reached that conclusion after surveying surgeons who had seen de-identified stories of surgical procedures with adverse events such as wrong eye implants, incorrect nerve blocks, and wrong-site excisions of lesions from Oct. 1, 2009, to June 30, 2011. The VHA selected stories in which the errors were traced to human factors and made the information available to all VHA physicians.
VHA chiefs of surgery were surveyed to determine how seeing the stories affected them and their behavior. Eighty-seven percent of those who had seen the stories said they were valuable, and 85% said the stories of other surgeons’ errors prompted them to improve or reinforce patient safety behaviors. (The study is available online at http://tinyurl.com/ocmhs37.)
Another VHA study addressed how effective the he Universal Protocol has been with the prevention of wrong-surgery procedures. Researchers focused on those errors that still would have happened even if the surgical team had complied with all aspects of the Universal Protocol. In these cases, the team might not have followed the Universal Protocol, but that omission is not what caused the error. “Understanding why some of these events are not caught by the steps of the Universal Protocol, culminating in the time-out, can help the field to add upstream and downstream safeguards to help prevent these never events,” they write.
The researchers used the 308 root cause analyses for incorrect surgical procedures in the VHA database between 2004 and 2013. They found 48 cases (16%) that were traced to errors upstream, before the Universal Protocol steps are implemented, or downstream, after the steps. Mislabeling of specimens was an upstream error, for example, and a surgical mistake after the procedure began was a downstream error. The incidence of such errors was not uniform across all procedures. Those errors were more likely to be found in wrong-level spine operations, wrong patient prostatectomies, wrong implant cataract procedures, and wrong-site skin lesion excisions, the researchers reported.
“Wrong surgery events can and do occur despite adherence to Universal Protocol including a time-out,” the researchers write. “The prevention of incorrect procedures requires complementary safety behaviors and technologies to address errors that occur upstream and downstream to the Universal Protocol and the time-out.”
The study is available online at http://tinyurl.com/nu3rawk.
