VA OIG Review of Patient Safety in the Operating Room in Veterans Health Administration Facilities

Review of Patient Safety in the Operating Room in Veterans Health Administration Facilities [05-00379-91], February 28, 2007.

  • “This review was conducted to evaluate Veterans Health Administration (VHA) medical facilities’ efforts to ensure patient safety in the operating room (OR). Our purpose was to determine whether: (1) facility leaders established and implemented effective policies, procedures, and guidelines to ensure patient safety in the OR; (2) facility leaders established a surgical improvement program that identifies potential problem areas needing improvement; and (3) there was coordination between Supply, Processing, and Distribution (SPD) and the OR. We found that most OR personnel followed the five steps outlined in VHA policy to ensure correct surgery; however, not all elements of the policy were consistently followed.”
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