Sharing lessons learned to prevent incorrect surgery.

Area of Science:

• Patient Safety
• Surgical Quality Improvement
• Human Factors Engineering

Background:

• The Veterans Health Administration (VHA) established a system for sharing deidentified surgical adverse event narratives.
• This initiative aims to improve patient safety by analyzing real-world surgical errors and near misses.

Purpose of the Study:

• To discuss lessons learned from surgical adverse events within the VHA.
• To recommend actions based on these lessons.
• To assess the awareness and impact of the VHA's surgical lessons learned process.

Main Methods:

• Analysis of deidentified surgical adverse event cases from October 2009 to June 2011.
• Inclusion of case examples illustrating human factors principles.
• A survey distributed to VHA Chiefs of Surgery to gauge the impact of the lessons learned program.

Main Results:

• Survey response rate was 76% (88/132).
• Of those aware of the program (76%), 87% found the lessons learned valuable.
• 85% reported that the program changed or reinforced patient safety behaviors.

Conclusions:

• Surgical lessons learned are perceived as valuable by VHA surgeons and impact practice.
• Human factors must be considered in adverse event reviews to prevent errors and policy non-adherence.
• Effective patient safety requires more than policy; it necessitates understanding human factors in adverse events.