One in Five Adverse Events Reported to VA Medical Centers due to Poor Communication

Poor communication was the cause of one in five adverse events reported to the Veterans Health Administration system from 2001 to 2006, according to a study published in November's Archives of Surgery (archsurg.ama-assn.org/cgi/content/abstract/144/11/1028/). Problems during the perioperative timeout process were a root cause of errors more than 15% of the time.

About half the mistakes occurred in operating rooms, while the other half involved minor surgical procedures performed outside the OR.

Full Article at: Wrong surgeries a product of poor communication

Mix-ups both inside and outside the operating room lead to procedures performed on the incorrect patient or wrong body part, a new study says.

By Kevin B. O'Reilly, amednews staff. Posted Dec. 11.
Communication failures such as poor handoff of critical information between surgical team members are the leading cause of surgeries involving the wrong patient, the wrong side, the wrong body part, the wrong implant or the wrong procedure.

Poor communication was the cause of one in five adverse events reported to the Veterans Health Administration system from 2001 to 2006, according to a study published in November's Archives of Surgery (archsurg.ama-assn.org/cgi/content/abstract/144/11/1028/). Problems during the perioperative timeout process were a root cause of errors more than 15% of the time.

The mistakes appeared to be rare, occurring once every 18,955 surgeries, although a definitive wrong surgery rate could not be established, because some errors go unreported, the study found. A total of 209 adverse events were reported, as were 314 "close calls" in which mistakes were caught before patients were harmed. Of the adverse events, 12% were serious enough to merit root cause analyses.

The VA system in January 2003 adopted a directive for preventing wrong surgeries. The Joint Commission's similar protocol took effect in June 2004. The safety procedures require surgeons and other health professionals to implement a redundant system of checks of the patient's identity, test results, the procedure to be performed and the surgical site. A pre-op timeout for one last check also should be performed.

When those steps are followed, wrong surgeries do not happen, said study co-author James P. Bagian, MD. "We didn't have any adverse events reported where people followed the procedures," said Dr. Bagian, director of the VA's National Center for Patient Safety since 1998.

About half the mistakes occurred in operating rooms, while the other half involved minor surgical procedures performed outside the OR. Studies have estimated that between five and 10 wrong surgeries occur every day in the U.S."

Often Overlooked Aid for War Time Veterans

Full Article at: Little known benefit aids war-time veterans, spouses

Editor:

"Those who serve during conflict are eligible for up to $19,000 a year. A little-known benefit for long-term care expenses is available to war-time veterans and their spouses. But the benefit is being overlooked by thousands of families.

The special pension for Veterans Aid and Attendance pays up to $1,644 a month, $19,736 annually toward assisted living, nursing homes or in-home care for veterans 65 and older who served at least 90 days and one day during war-time - stateside or overseas. Veterans and their spouses can receive up to $23,396 annually and spouses of deceased veterans $12,681. Yet, an estimated $22 billion a year goes unclaimed each year.

In 2007, only 134,000 seniors nationwide received the benefit, which was established in 1952. The Veterans Administration will provide help to families to complete the necessary forms so that approval comes in four to six months. The process is streamlined for vets who are blind or have memory issues and widows with medical needs. Most applicants qualify and payments are retroactive."