Nellis hospital pushes safety in wake of errors

A recent series of surgery miscues, including the death of a patient after a gall bladder procedure, at Mike O'Callaghan Federal Hospital prompted a stand-down safety day this week at the Nellis Air Force Base hospital.

Col. John DeGoes, commander of the 99th Medical Group at Nellis, and John Bright, director of the Veterans Affairs Southern Nevada Healthcare System, confirmed Thursday that surgical teams attended the safety stand-down conference.

All scheduled, elective surgeries and non-life-threatening procedures were canceled Monday while surgeons, physicians, nurses and support staff huddled to review the surgical incidents and chart a course to prevent them.

It was the first such stand-down safety day since DeGoes took command of the hospital in the summer of 2010. There have, however, been rolling stand-down training days for various shifts at the base hospital, where local armed forces veterans and active-duty Air Force personnel are treated.

"I would not call it an emergency. It was planned a couple of weeks in advance," DeGoes said about the stand-down.

He said the goal of the conference was to build trust among team members and to "cultivate a culture of safety" without stifling openness among the hospital staff.

Citing federal privacy regulations, DeGoes and Bright would not discuss specifics of any particular case or patient but they did confirm certain incidents had occurred since April, of which one -- the June 19 gall bladder procedure -- was deadly or life-threatening. Medical officials call such incidents "sentinel events."

Jacob Hafter, a private attorney who has represented clients in high-profile medical cases, provided a list of five incidents that occurred at Mike O'Callaghan Federal Hospital and were discussed at the stand-down conference.

He said the federal hospital incidents were all preventable mistakes similar to those mentioned in a 1999 Institute of Medicine report "To Err is Human." The report referenced two studies that found between 44,000 and 98,000 people die in hospitals each year because of medical errors that could have been prevented.

"There's something going on at Nellis that is causing these type of events to occur," Hafter said Thursday.

"This is far above the national average for what's acceptable at a VA hospital. It is yet another example of inadequate care that residents of our community are being exposed to."

Hafter said he is representing a "concerned physician who is extremely frustrated" by the federal hospital matter. His incident list described the following:

■ A wrong site blocked by an anesthesiologist in April.

■ An incision made on the wrong side of a bone in June that hospital officials said was corrected during surgery.

■ A lacerated vein during a June 19 procedure in which the patient died.

■ Two incidents of wrong sites marked but caught before surgeries in August.

■ A hearing device that was implanted this month in the ear a patient had requested but not the ear that a doctor had recommended.

After the last miscue, DeGoes said he was concerned about the procedure but didn't feel there was any clear danger in the operating room.

"It was not like a plane crashed and fell out of the sky, and you wanted to stop immediately," he said, adding that is when he planned the stand-down for two weeks later.

The mistakes were either caught in time or resulted in no health adversities except for the death of a patient whose portal vein was severed during a laparoscopic procedure to remove a gall bladder. The surgeon used a pencil-size, lighted tube inserted through an incision in the abdominal wall.

Bright defended the track record at Mike O'Callaghan Federal Hospital which was presented with "best patient safety" awards by the Air Force in 2008, the Department of Defense in 2009 and 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 said.

"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."

An estimated 40 wrong-site surgeries per week occur in the United States, according to a report this year by the Joint Commission for Transforming Health Care.

In 2010, the Nevada State Health Division reported 11 wrong-site or wrong-person surgeries in the state based on sentinel event data supplied by Nevada health facilities. Of the 11, three procedures were done on the wrong person, and eight were performed on the wrong part of a patient's body.

One division official has said he suspects sentinel events have been underreported or misreported.

DeGoes said all incidents at the Nellis hospital are reported and peer reviewed. The federal hospital at Nellis has had "significantly less than 11" for the same period, he said.

"I know we did. And if you define if you actually did the surgery, we weren't even close. We would be in the lowest of the single digits for actual completed wrong-site surgeries," he said.

Bright said with the new VA medical center expected to open next year in North Las Vegas, he is preparing for routine safety stand-downs, starting with weekly or monthly sessions with the new staff, to prevent wrong-site incidents.

"As a matter of practice, the VA will have a stand-down at a minimum of six months to make sure all staff is on board," he said. "The critical point here is making every one on the surgical team understand, regardless of where they are on the food chain, that they can stop the process."

Contact reporter Keith Rogers at krogers@review journal.com or 702-383-0308.