Power Failures During Surgery: A 2000-2019 Review of Reported Events in the Veterans Health Administration

Area of Science:

• Healthcare Quality Improvement
• Patient Safety in Surgery
• Health Systems Analysis

Background:

• The frequency and impact of power failures during surgical procedures within large healthcare systems like the Veterans Health Administration (VHA) remain largely undocumented.
• Ensuring patient safety and high-quality surgical care necessitates minimizing risks associated with rare but potentially catastrophic power failure events.

Purpose of the Study:

• To analyze the frequency and impact of power failures occurring during surgical procedures within the VHA from January 2000 to March 2019.
• To identify common causes and contributing factors of power failures during surgery in a major integrated healthcare system.

Main Methods:

• A quality improvement study analyzing patient safety adverse events related to operating room power failures.
• Data sourced from 63 VHA medical centers, including 20 root cause analyses and 135 safety reports submitted to the VHA National Center for Patient Safety.

Main Results:

• The primary causes of power failure events were generator delays (36.1%), equipment reboot delays (21.9%), and backup power failures (13.5%).
• Identified root causes encompass issues with backup power systems, inter-staff communication, procedural standardization, and training.
• Patient harm was reported in 18% of events, with 3.9% classified as major or catastrophic.

Conclusions:

• Power failures during surgery, while infrequent, are linked to severe patient harm.
• Enhanced disaster preparedness, staff focus on potential failures, and improved communication strategies are crucial for preventing or reducing patient harm.