National Center for Patient Safety, Veterans Health Administration, White River Junction, Vermont.
Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
JAMA Netw Open. 2018 Nov 2;1(7):e185147. doi: 10.1001/jamanetworkopen.2018.5147.
Reducing wrong-site surgery is fundamental to safe, high-quality care. This is a follow-up study examining 8 years of reported surgical adverse events and root causes in the nation's largest integrated health care system.
To provide a follow-up description of incorrect surgical procedures reported from 2010 to 2017 from US Veterans Health Administration (VHA) medical centers, compared with the previous studies of 2001 to 2006 and 2006 to 2009, and to recommend actions for future prevention of such events.
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study describes patient safety adverse events and close calls reported from 86 VHA medical centers from the approximately 130 VHA facilities with a surgical program. The surgical procedures and programs vary in size and complexity from small rural centers to large, complex urban facilities. Procedures occurring between January 1, 2010, and December 31, 2017, were included. Data analysis took place in 2018.
The categories of incorrect procedure types were wrong patient, side, site (including wrong-level spine), procedure, or implant. Events included those in or out of the operating room, adverse events or close calls, surgical specialty, and harm. These results were compared with the previous studies of VHA-reported wrong-site surgery (2001-2006 and 2006-2009).
Our review produced 483 reports (277 adverse events and 206 close calls). The rate of in-operating room (in-OR) reported adverse events with harm has continued to trend downward from 1.74 to 0.47 reported adverse events with harm per 100 000 procedures between 2000 and 2017 based on 6 591 986 in-OR procedures. When in-OR events were examined by discipline as a rate, dentistry had 1.54, neurosurgery had 1.53, and ophthalmology had 1.06 reported in-OR adverse events per 10 000 cases. The overall VHA in-OR rate for adverse events during 2010 to 2017 was 0.53 per 10 000 procedures based on 3 234 514 in-OR procedures. The most common root cause for adverse events was related to issues in performing a comprehensive time-out (28.4%). In these cases, the time-out either was conducted incorrectly or was incomplete in some way.
Over the period studied, the VHA identified a decrease in the rate of reported adverse events in the OR associated with harm and continued reporting of adverse event close calls. Organizational efforts continue to examine root cause analysis reports, promulgate lessons learned, and enhance policy to promote a culture and behavior that minimizes events and is transparent in reporting occurrences.
降低错误部位手术是安全、高质量护理的基础。这是一项后续研究，调查了全国最大的综合性医疗保健系统中 8 年来报告的手术不良事件和根本原因。
提供 2010 年至 2017 年期间，从美国退伍军人健康管理局（VHA）医疗中心报告的错误手术程序的后续描述，与之前 2001 年至 2006 年和 2006 年至 2009 年的研究进行比较，并为未来预防此类事件提出建议。
设计、设置和参与者：这项质量改进研究描述了 86 个 VHA 医疗中心从大约 130 个具有手术项目的 VHA 设施中报告的患者安全不良事件和接近事件。手术程序和程序的规模和复杂性从小型农村中心到大型复杂的城市设施各不相同。包括 2010 年 1 月 1 日至 2017 年 12 月 31 日期间发生的手术。数据分析于 2018 年进行。
错误程序类型的类别包括错误患者、侧位、部位（包括错误脊柱水平）、程序或植入物。事件包括手术室内外、不良事件或接近事件、手术专业和伤害。这些结果与之前 VHA 报告的错误部位手术（2001-2006 年和 2006-2009 年）研究进行了比较。
我们的审查产生了 483 份报告（277 份不良事件和 206 份接近事件）。根据 2000 年至 2017 年期间 6591986 例手术中，手术室内报告的不良事件与伤害的发生率从 1.74 下降到 0.47 每 100000 例手术。当以学科为指标检查手术室内事件的发生率时，牙科为 1.54，神经外科为 1.53，眼科为 1.06，每 10000 例手术中有手术室内不良事件。根据 2010 年至 2017 年期间的 3234514 例手术室内手术，VHA 手术室内不良事件的总发生率为每 10000 例手术 0.53。不良事件的最常见根本原因与全面暂停期间的问题有关（28.4%）。在这些情况下，暂停要么不正确地进行，要么以某种方式不完整。
在研究期间，VHA 确定了与伤害相关的手术室内报告不良事件的发生率下降，并继续报告不良事件的接近事件。组织继续审查根本原因分析报告，宣传经验教训，并加强政策，以促进一种文化和行为，最大限度地减少事件，并在报告发生时保持透明。
