VA Medical Center Surgery Errors Declining: Study

Although thousands of veterans were told in 2009 that they may have been exposed to infected blood and or treated by a “rogue” cancer unit that was using radiation treatment without knowing what it was doing, some researchers say that 2009 was a good year for U.S. veterans hospitals when it came to surgical errors

According to a study published this month on-line by the Archives of Surgery, surgery mistakes at Veterans Affairs hospitals were on the decline in 2009, during the same year that multiple concerns emerged about the quality of care at several VA medical centers.

Researchers looked at surgery errors from 2006 through 2009 at VA hospitals and found that the number of monthly adverse events reported dropped from 3.2 in 2006 to 2.4 in 2009. However, so-called “close calls,” where adverse events were just barely averted, increased from 1.97 per month to 3.24 per month. About half of the adverse events took place in the operating room.

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The researchers concluded that the most common cause for VA medical center surgical errors was a lack of standardization of clinical processes. They also concluded that safety measures that increased communication may have played a major role in decreasing those numbers.

Despite the bad press the VA received in 2009, there was a focus on improving safety that included an increase in preoperative briefings and postoperative debriefings and other communication changes in how medical teams at the hospitals worked.

There are still ways the VA can improve safety, the researchers said, by standardizing clinical procedures and adding more safety steps to prevent wrong site surgeries in neurosurgery and to prevent installing the wrong implants in ophthalmology procedures. The researchers pointed out that there was a lot of variability in the number of adverse events reported from one facility to the other.

The VA hospital system faced substantial criticism over the quality of medical treatment provided at medical clinics in several states throughout the course of 2009. Investigators from the Nuclear Regulatory Commission reported in June that a cancer unit at the Philadelphia VA Medical Center mishandled nearly 100 cases involving radiation treatment and suggested that staff involved had altered records to cover mistakes.

During 2009, the VA also faced the fallout from colonoscopy problems at VA centers in Tennessee, Georgia and Florida, where contaminated equipment exposed thousands of veterans to hepatitis, HIV and other blood borne diseases.

Lawmakers blasted the VA in a hearing that July for the repeated lapses in veteran care.

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