Errors Spur Surgery Standdown at Nellis

November 14, 2011

As the following article reminds us, injuries and complications that might be avoided with better care can and do happen to patients, even in good hospitals, and even in hospitals staffed by the most dedicated and well-trained personnel.  That includes the health care centers of the U.S. Armed Forces.  

By Scott Fontaine - Staff writer
Air Force Times
Posted : Saturday Oct 15, 2011 8:36:23 EDT

Surgeons are back to work at Nellis Air Force Base, Nev., after a daylong safety standdown to review a string of medical mistakes, including the death of a patient after a routine gallbladder operation.

Col. John DeGoes of the 99th Medical Group ordered the Sept. 19 standdown at Mike O’Callaghan Federal Hospital so medical staff members could discuss several preventable incidents that occurred in the past few months.

The hospital, run jointly by the Air Force and Veterans Affairs Department, performed almost 4,300 surgeries last year, about two-thirds of them on airmen and their family members. The number of patients totaled more than 260,000.

DeGoes did not publicly announce the standdown, which canceled elective surgeries and nonlife-threatening procedures; details of the review came from Jacob Hafter, a lawyer representing a civilian physician at the hospital concerned with the level of care.
About three-quarters of the hospital’s more than 2,000 workers are airmen or Air Force civilians, and the rest are VA employees.

Hafter alleged a “plethora of preventable injuries” at the hospital, including:
• An anesthesiologist blocked the wrong site on a patient in April.
• An orthopedist made an incision on the wrong forearm bone in June.
• A doctor lacerated the portal vein during surgery to remove a patient’s gallbladder in June. The patient bled to death.
• The wrong surgery site was marked during two procedures in August, but both were caught before surgery began.
• An otolaryngologist implanted a device in the wrong ear of a patient in September.

Hospital officials also discussed miscommunications, a lack of accountability and paperwork errors, according to notes from Hafter’s client.
DeGoes declined to be interviewed, citing concerns over patient privacy. In a statement, however, DeGoes said the standdown helped medical staff members “meet our safety objectives.”

“Our medical staff took time in an open and honest discussion forum in order to continue to improve the quality of care we provide, and to further build on the patient safety culture we highly value,” the statement read. “We took an unflinching look at our procedures and processes, both to identify areas we can do better and reinforce those we do well by ensuring our medical protocols continue to be followed.”

Later, Nellis spokesman Todd Lane provided written responses to questions from Air Force Times.

DeGoes scheduled the standdown almost three weeks in advance, issuing the order Sept. 1, according to the information from Lane. Several “good catches and two specific events that caused no permanent patient harm” prompted the standdown, according to the statement.

Other mistakes — aside from the death — were caught in time or resulted in no physical harm, he told Air Force Times.
Hafter, though, doubts DeGoes.

“When you have a standdown day, when you close your operating department because you need to practice safe medicine, that’s scary,” he said.

The hospital did not release the number of preventable deaths or “sentinel events,” errors that result in death or serious injury. Both statistics are protected by federal law “to ensure full cooperation by all involved in the investigation and ensure integrity of our quality assurance programs,” according to the information from Lane.

In the statement, the Air Force surgeon general reaffirmed the service’s commitment to patient safety.

“Patient safety is central to everything we do,” Lt. Gen. Bruce Green said. “By learning from mistakes and sharing information, we continually strive to enhance the quality of our care.”

Wrong-site surgeries — a term that includes surgeries on the wrong side of the patient’s body, on the wrong place on the patient’s body, the wrong procedure performed or surgery performed on the wrong patient — are rare. A 2008 study commissioned by the National Institutes of Health estimated as few as 1 in 112,994 surgeries were performed on the wrong site, although the report’s authors said as little as 10 percent of wrong-site surgeries are reported.

John Bright, of the Veterans Affairs Southern Nevada Healthcare System, defended the hospital to the Las Vegas Review-Journal by pointing to several patient safety awards, including best in the Air Force in 2008, best in the Defense Department in 2008 and best in Air Combat Command in 2010.

“Out of 4,000 to 5,000 surgeries [per year] I’ll put our safety record up against anybody, anywhere,” Bright told the newspaper. “I’ve been here 10 years, and in that 10 years, there has been one surgical complication of that [sentinel] event magnitude that I’m aware of. That’s a pretty damn good record when you consider the complexity of the patients we treat.”

For well over half a century, the law of the United States has recognized the right of citizens to seek compensation for injury resulting from negligent government health care.  If you believe that you or a loved one have suffered an avoidable injury due to errors or omissions in military or VA medical care, the experienced attorneys at Rawls, McNelis and Mitchell are standing by to evaluate your case at no expense, and to help you obtain compensation.  

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