MP66-19 INVESTIGATION OF UROLOGY INTRAOPERATIVE EVENTS LEADING TO ROOT CAUSE ANALYSIS AT NATIONAL VETERANS AFFAIRS MEDICAL CENTERS

Abstract

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety III (MP66)1 Apr 2020MP66-19 INVESTIGATION OF UROLOGY INTRAOPERATIVE EVENTS LEADING TO ROOT CAUSE ANALYSIS AT NATIONAL VETERANS AFFAIRS MEDICAL CENTERS Leslie M. Peard*, William Gunnar, Peter Mills, and Andrew M. Harris Leslie M. Peard*Leslie M. Peard* More articles by this author , William GunnarWilliam Gunnar More articles by this author , Peter MillsPeter Mills More articles by this author , and Andrew M. HarrisAndrew M. Harris More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000941.019AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Root Cause Analysis (RCA) is a well-known and effective method of analyzing errors made in the healthcare setting. We aimed to categorize events leading to RCA in urology ORs at VA medical centers in order to increase understanding of when RCA may be appropriate and if where changes may be implemented as a result. METHODS: A dataset of surgery RCAs at VA medical centers that were submitted between the start of fiscal year 2015 to present was created using terms including urology, -gic, -gist, vasectomy; prostatectomy (including TURP, RRP, LRP, PVP), nephrectomy, cystectomy, cystoscopy, lithotripsy, kidney stone, ureteroscopy, ureter, -al, urethral, TURBT, bladder/prostate cancer, and gleason. Cases that did not pertain to an event in a urology OR were excluded. The cases were then categorized based on the type of event. RESULTS: A total of 62 cases were identified. The most common pattern identified was equipment or instrument issue with 23 cases. For example, ‘no sterile flexible ureteroscopes available for scheduled ureteroscopy identified after patient asleep’; ‘smoking light cord’. There were 12 events categorized as retained foreign bodies (surgical sponge, retained guidewire), 8 pertaining to medical or anesthesia event (incorrect dosing, STEMI during TURP), and 7 pertaining to pathology errors (missing specimen, incorrect diagnosis later revised, mislabeled specimen). There were 6 wrong site surgeries (wrong side ureteral stent placement, prostate biopsy performed in patient scheduled for cystoscopy), 5 cases with incorrect patient information or consent (TURBT performed without consent), and 4 cases identified as major surgical complications (renal artery injury during ureteroscopy, unrecognized bladder perforation during TURP). In 2 cases the wrong case was performed or there was inappropriate work up. One case caused a significant delay in treatment, one case pertained to an incorrect count, and one case identified lack of appropriate credentialing. CONCLUSIONS: RCA is an important tool in improving quality and safety of care. We identified several patterns of events leading to RCA pertaining to urologic operating rooms. By categorizing theses variables, we can better identify targets for efforts on improving quality and safety in our operating rooms. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e991-e992 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leslie M. Peard* More articles by this author William Gunnar More articles by this author Peter Mills More articles by this author Andrew M. Harris More articles by this author Expand All Advertisement PDF downloadLoading ...