Causes of wrong surgery events in VHA despite Universal Protocol

The Universal Protocol has been associated with the prevention of wrong surgery events, but events still occur.

This study from the Veterans Health Administration (VHA) explored wrong surgery events in the VHA database of root cause analyses to determine the frequency and characteristics of these events, which occurred because of errors upstream and downstream to the Universal Protocol.

The analysis included 48 cases of wrong surgery events, representing 16% of the 308 root cause analyses for events reported between 2004 and 2013.

Upstream errors included mislabeling of specimens or radiographs and transposition of reports. Downstream errors, which occurred after time-outs were performed, were associated with ineffective intraoperative processes, including wrong level spine localization errors, other intraoperative localization errors, and intraprocedure diagnostic determinations.

Surgical procedures that were particularly vulnerable included spine (wrong level), prostatectomy (wrong patient), cataract (wrong implant), and skin lesion excisions (wrong lesion).

The researchers concluded that healthcare organizations cannot rely on compliance with performance of the Universal Protocol to eliminate the possibility of a wrong surgery event. Prevention of such events will require diligence upstream and downstream from the Universal Protocol.

—Paull D E, Mazzia L M, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. Am J Surg. 2015;210(1):6-13.

http://www.americanjournalofsurgery.com/