Medical errors down at U.S. veterans' hospitals

NEW YORK (Reuters Health) - The rate of medical errors is down at the U.S. Veterans Health Administration (VHA), according to a new report.

The number of close calls has gone up, by contrast, a fact researchers say hints at a new awareness and openness about hospital mistakes.

"The fact that close calls have gone up while harm and adverse events have gone down is a good sign, I think," Julia Neily from the VHA in White River Junction, Vermont, told Reuters Health.

Medical errors are a widespread problem in the U.S., occurring in about one in 75,000 surgeries every year, according to Dr. Martin A. Makary, a surgeon at Johns Hopkins University in Baltimore, who was not involved in the study.

"In the world of the health care system it ranks low compared to other harms," he told Reuters Health last year, "but it ranks high in terms of preventable harms."

To try to solve the problem, the VHA -- the largest integrated health care system in the U.S. -- has introduced checklists and special training that stresses teamwork among its staff.

"We really take a multipronged approach to this," said Neily, whose findings appear in the Archives of Surgery. "We want people to speak up if they think a mistake has occurred."

And it appears the work has paid off.

Between 2006 and 2009, Neily and her colleagues found, there were 101 real errors -- like operating on the wrong patient or on the wrong side of the body -- and 136 close calls.

Over that period, the number of errors dropped from 3.2 per month to 2.4, while the number of monthly close calls shot up from 2 to 3.2.

Including the results from an earlier study, the rate of self-reported errors dipped from 1.7 to 0.5 per 100,000 procedures between 2001 and 2009.

Wrong-patient and wrong-side procedures were the most common mistakes. Diagnostic imaging like CAT scans using dyes injected in the blood accounted for the majority of the wrong-patient procedures.

"It comes down to communication," Neily said. "In the same way we encourage all healthcare team members to speak up and be involved, the concept that we are promoting at the National Center for Patient Safety is again to speak up."

SOURCE: bit.ly/nSmCHf Archives of Surgery, online July 18, 2011.