title: Sharing lessons learned to prevent incorrect surgery.
abstract: The purpose of this report is to discuss surgical adverse event lessons learned and to recommend action. Examples of incorrect surgical adverse events managed in the Veterans Health Administration (VHA) patient safety system and results of a survey regarding the impact of the surgery  lessons learned process are provided. The VHA implemented a process for sharing deidentified stories of surgical lessons learned. The cases are in-operating room selected examples from lessons learned from October 1, 2009, to June 30, 2011. Examples selected illustrate helpful human factors  principles. To learn more about the awareness and impact of the lessons learned, we conducted a survey with Chiefs of Surgery in the VHA. The types of examples of adverse events include wrong eye implants, incorrect nerve blocks, and wrong site excisions of lesions. These are accompanied by  human factors recommendations and change concepts such as designing the system to prevent mistakes, using differentiation, minimizing handoffs, and standardizing how information is communicated. The survey response rate was 76 per cent (88 of 132). Of those who had seen the surgical lessons  learned (76% [67 of 88]), the majority (87%) reported they were valuable and 85% that they changed or reinforced patient safety behaviors in their facility as a result of surgical lessons learned. Simply having a policy will not ensure patient safety. When reviewing adverse events, human factors  must be considered as a cause for error and for the failure to follow policy without assigning blame. VHA surgeons reported that the surgery lessons learned were valuable and impacted practice.
authors.affiliation: Veterans Health Administration, White River Junction, Vermont, 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: Douglas E
authors.initials: DE
authors.lastname: Paull
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Mazzia
authors.forename: James R
authors.initials: JR
authors.lastname: Turner
authors.forename: Robin R
authors.initials: RR
authors.lastname: Hemphill
authors.forename: William
authors.initials: W
authors.lastname: Gunnar
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D061214:Patient Safety; D011183:Postoperative Complications / Q000209:etiology* / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D013514:Surgical Procedures, Operative / Q000592:standards*