Communication problems in and out of the OR persist and performing pre-op time outs might not be enough to prevent serious adverse events from happening, say researchers at the Veterans Health Administration after their 5-year review of 130 VHA facilities.

The researchers analyzed 342 safety breaches reported at VHA medical centers between January 2001 and June 2006. They report that 212 involved procedures performed unnecessarily — surgical procedures or diagnostic testing on the wrong patient or body part, for example — and 130 close calls. Approximately half of the adverse events occurred in the OR, according to the study's findings, which appear in the November issue of Archives of Surgery.

Ophthalmic and orthopedic cases accounted for the highest number of adverse events reported in the OR, notes the study, which identifies inadequate communication between caregivers as the most common cause of incorrect surgical procedures.

The study's authors say surgical professionals should discuss key procedure information before patients enter the OR and base their pre-op communication on aviation crew resource management programs.

Daniel Cook