Abstract
A systematic review of incorrect surgery and invasive procedure root cause analyses from the Veterans Health Administration’s safety reporting system revealed three important and recurring attributes: (1) these events often occur outside an operating room; (2) frequently involve a wrong implant; (3) or wrong surgical site level. Fifty-two “time-out” videos on the internet over the years 2010–2015 were reviewed to determine if these key characteristics were demonstrated or discussed. Of the reviewed videos only one (1.9%) incorporated all of the aforementioned attributes while twenty-one (40.4%) failed to address any of the critical components. Internet time-out videos fail to portray the important characteristics of incorrect surgery or invasive procedure, a finding which is unlikely to help further reduce such adverse events. In the future, patient safety educators will need to adjust their screenplays, expand their curricula, or entertain new learner formats to highlight the context and cause of today’s incorrect procedures.
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Acknowledgements
This material is based upon work supported by the Department of Veterans Affairs, the Veterans Health Administration, and the National Center for Patient Safety. The contents of this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. Work supported by Grant # DM150022 from the U.S. Army Medical Research and Material Command (USAMRMC), Fort Detrick, MD.
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Paull, D.E., Kononowech, R., Simpson, S., Sine, D.M., Hemphill, R.R. (2018). Incorrect Surgery and Invasive Procedures: Internet Videos Fail to Depict the Full Story. In: Duffy, V., Lightner, N. (eds) Advances in Human Factors and Ergonomics in Healthcare and Medical Devices. AHFE 2017. Advances in Intelligent Systems and Computing, vol 590. Springer, Cham. https://doi.org/10.1007/978-3-319-60483-1_49
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