title: Incorrect surgical procedures within and outside of the operating room.
abstract: OBJECTIVE
  To describe incorrect surgical procedures reported from Veterans Health Administration (VHA) Medical Centers from 2001 to mid-2006 and provide proposed solutions for preventing such events.
  
  
  METHODS
  Descriptive study.
  
  
  METHODS
  Veterans Health Administration Medical Centers.
  
  
  METHODS
  Veterans of the US Armed Forces.
  
  
  METHODS
  The VHA instituted an initial directive, "Ensuring Correct Surgery and Invasive Procedures," in January 2003. The directive was updated in 2004 to include non-operating room (OR) invasive procedures and incorporated requirements of The Joint Commission Universal Protocol for preventing wrong-site operations.
  
  
  METHODS
  The categories included 5 incorrect event types (wrong patient, side, site, procedure, or implant), major or minor surgical procedures, location in or out of the OR, therapeutic or diagnostic events, adverse event or close call, inpatient or ambulatory events, specialty department, body segment, and severity and probability of harm.
  
  
  RESULTS
  We reviewed 342 reported events (212 adverse events and 130 close calls). Of these, 108 adverse events (50.9%) occurred in an OR, and 104 (49.1%) occurred elsewhere. When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2%] each), whereas orthopedics was second to ophthalmology for number of reported adverse events occurring in the OR. Pulmonary medicine cases (such as wrong-side thoracentesis) and wrong-site cases (such as wrong spinal level) were associated with the most harm. The most common root cause of events was communication (21.0%).
  
  
  CONCLUSIONS
  Incorrect ophthalmic and orthopedic surgical procedures appear to be overrepresented among adverse events occurring in ORs. Outside the OR, adverse events by invasive radiology were most frequently reported. Incorrect surgical procedures are not only an OR challenge but also a challenge for events occurring outside of the OR. We support earlier communication based on crew resource management to prevent surgical adverse events.
authors.affiliation: Department of Veterans Affairs, Veterans Health Administration, White River Junction, VT 05009, USA. julia.neily@va.gov
authors.forename: Julia
authors.initials: J
authors.lastname: Neily
authors.forename: Peter D
authors.initials: PD
authors.lastname: Mills
authors.forename: Noel
authors.initials: N
authors.lastname: Eldridge
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Dunn
authors.forename: Carol
authors.initials: C
authors.lastname: Samples
authors.forename: James R
authors.initials: JR
authors.lastname: Turner
authors.forename: Audrey
authors.initials: A
authors.lastname: Revere
authors.forename: Ralph G
authors.initials: RG
authors.lastname: DePalma
authors.forename: James P
authors.initials: JP
authors.lastname: Bagian
mesh_terms: D000556:Ambulatory Surgical Procedures / Q000009:adverse effects* / Q000706:statistics & numerical data; D002423:Cause of Death; D005260:Female; D019538:Health Care Surveys; D017052:Hospital Mortality / Q000639:trends*; D006787:Hospitals, Veterans; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000401:mortality; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D016017:Odds Ratio; D009873:Operating Rooms; D009885:Ophthalmology / Q000592:standards / Q000639:trends; D009985:Orthopedics / Q000592:standards / Q000639:trends; D011183:Postoperative Complications / Q000401:mortality; D011336:Probability; D011787:Quality of Health Care; D012189:Retrospective Studies; D018570:Risk Assessment; D017751:Safety Management; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000379:methods; D016019:Survival Analysis; D014481:United States