Reported event rates fell from 3.21 per month in 2006 to 2.4 per month in 2009 (P=0.02), according to Julia Neily, RN, of the Veterans Health Administration in White River Junction, Vt., and colleagues.
And analysis of events most likely to cause the greatest harm found that these events decreased by an annual rate of 14% (rate ratio 0.86, 95% CI 0.75 to 0.97, P=0.02), the research team reported online in the Archives of Surgery.
"Wrong-site surgery is the reviewable sentinel event most frequently reported to the Joint Commission and has been estimated to occur at a rate of 0.09 to 4.5 per 10,000 cases," the researchers stated.
In recent years the VA has made patient safety a priority, implementing a medical team training program that emphasizes preoperative checklists and postoperative briefings.
To assess the efficacy of these efforts, Neily and colleagues analyzed reports filed with the VA National Center for Patient Safety for events given the highest rating for potential harm.
They identified 237 cases, 101 of which involved actual harm and 136 close calls, where significant harm could have occurred but was averted.
Types of events included wrong patient, procedure, site, side, and implant.
The type of event associated with the highest rating for harm was wrong procedure (P=0.02), the researchers found.
A total of 150 events took place in the operating room, 58 occurred at other sites such as procedure rooms and radiology departments, and in 29 cases the site was not specified.
Although actual events leading to harm decreased over the study period, close calls increased from 1.97 to 3.24 each month (P<0.001).
The highest rate of events in the operating room was in neurosurgery, at 1.56 per 10,000 cases, followed by ophthalmology, with 1.06 per 10,000.
The neurosurgery events most often were the wrong site during spinal surgery, which the VA has addressed through measures such as mandating the confirmation of the position of the spine marker by the surgeon and requiring marking of the site before the anesthetic is administered in regional nerve blocks.
In ophthalmology, problems most commonly involved the placement of incorrect lenses, occurring in 13 of 22 cases.
When the researchers looked at the root causes for these events, they found the most common to be a lack of standardization of critical clinical processes and procedures, as well as human factors such as difficulties with machinery and operator fatigue.
The VA is continuing its efforts toward limiting patient harm.
"Current plans and actions include continuing to share detailed lessons learned from root cause analyses, rapid notification of adverse events, policy changes as needed based on root cause analysis review, and additional focused [medical team training] for sites as needed," wrote Neily and colleagues.
Limitations of the study included the self-report of adverse events, inadequate information in some reports, and a lack of demographic data.
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