Safety in surgical and medical procedures should be paramount, two studies… (ER Productions/CORBIS )
No one wants to have errors made during surgery or other medical procedures, but it happens. Two studies--one focusing on analyzing wrong-site and wrong-patient procedures and another on a program emphasizing teamwork and reducing surgical deaths--highlight the importance of safety and communication.
The first study, released Monday in Archives of Surgery, analyzed 27,370 unfavorable events that happened between 2002 and 2008 in Colorado. Among those events were 25 wrong-patient and 107 wrong-site procedures, with five of the wrong-patient and 38 of the wrong-site procedures ending in substantial harm to the patients. A wrong-site procedure resulted in the death of one patient.
In 2004, the Joint Commission, a nonprofit accreditation and certification organization, issued a Universal Protocol for ambulatory care facilities, office-based surgery facilities and accredited hospitals that included safety measures such as marking the procedure site, doing a time-out before the procedure, and doing a pre-procedure verification.
In the study, researchers categorized the causes behind the errors that occured. Mistakes in diagnosis accounted for 56% of wrong-patient procedures and 12.1% of wrong-site procedures. Errors in communication were a factor in 100% of wrong-patient procedures and 48.6% of wrong-site procedures. Mistakes in judgment were the main cause of 85% of wrong-site cases and and 8% of wrong-patient procedures.
The second study, released Tuesday in the Journal of the American Medical Assn., focused on a Veterans Health Administration Medical Team Training program established in 2006 that encourages teamwork and emphasizes safety procedures in surgery.
The program includes two months of preparation and planning with the surgical team, plus a one-day learning session on site. That's followed by four quarterly follow-up phone calls with the team for a year.
Over three years researchers followed 108 facilities; 74 received the training and 34 did not. Observed deaths declined 18% in the trained facilities, and dropped 7% in the untrained facilities. For every quarter of training, mortality rates went down 0.5 per 1,000 procedure deaths.
Almost half of the trained facilities said that communication improved among their operating room staff, 46% said there was better OR staff awareness, and about 65% said they noticed an improvement in OR teamwork.
--Jeannine Stein / Los Angeles Times