Key result
Among VHA Chiefs of Surgery who reviewed surgical lessons learned, 87% reported they were valuable and 85% reported that they changed or reinforced patient safety behaviors in their facility.
Cross-Sectional (n=88)
Yes
Sharing deidentified surgical lessons learned with human factors recommendations is perceived as valuable and positively impacts patient safety behaviors among VHA surgeons.
Supports sharing deidentified surgical lessons in VHA; leaves open effects on objective safety outcomes.
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.
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Neily et al. (2012) conducted a cross-sectional in Surgical adverse events (n=88). Surgical lessons learned process was evaluated on Perceived value and impact on patient safety behaviors. Among VHA Chiefs of Surgery who reviewed surgical lessons learned, 87% reported they were valuable and 85% reported that they changed or reinforced patient safety behaviors in their facility.
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