Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

Book/Report

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

October 25, 2023

Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.

Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.

Free full text (PDF)

Related Resources From the Same Author(s)

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee.

November 13, 2013

Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee.

January 31, 2024

Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus.

April 10, 2024

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

August 2, 2023

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

July 14, 2021

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

May 26, 2021

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

September 30, 2020

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Critical Deficiencies at the Washington DC VA Medical Center.

March 21, 2018

Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota.

January 29, 2020

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

November 29, 2023

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events.

November 16, 2011

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Adverse Events Toolkit: Medical Record Review Methodology.

July 26, 2023

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Adverse Events Toolkit: Clinical Guidance for Identifying Harm

July 19, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures.

January 24, 2024

Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.

November 8, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.

May 25, 2022

Medicare's Oversight of Ambulatory Surgery Centers Report.

October 23, 2019

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.

February 11, 2015

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

January 14, 2015

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

June 4, 2014

Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.

January 9, 2019

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

November 24, 2010

Adverse Events in Hospitals: Methods for Identifying Events.

March 17, 2010

Adverse Events in Hospitals: Public Disclosure of Information About Events.

January 20, 2010

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.

March 19, 2014

Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.

August 1, 2012

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

January 18, 2012

Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing.

August 9, 2017

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

February 1, 2023

Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.

April 22, 2020

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

February 18, 2009

Adverse Events in Hospitals: State Reporting Systems.

January 14, 2009

Adverse Events in Hospitals: Overview of Key Issues.

January 14, 2009

Trends in Nursing Home Deficiencies and Complaints.

October 29, 2008

The Food and Drug Administration's National Drug Code Directory.

September 6, 2006

Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.

May 20, 2020

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

June 13, 2012

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

Incidence of Adverse Events in Indian Health Service Hospitals.

December 23, 2020

Disclosure of Adverse Events to Patients.

November 16, 2005

Oversight Hearing on Recent Patient Safety Issues.

June 28, 2006

Patient Safety Organizations: Hospital Participation, Value, and Challenges.

October 16, 2019

Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications.

March 5, 2014

VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities.

January 4, 2006

Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors.

July 18, 2007

Hospital Reporting of Deaths Related to Restraint and Seclusion.

September 27, 2006

Nursing Home Complaint Investigations.

September 20, 2006

Evidence Brief: Implementation of High Reliability Organization Principles.

July 24, 2019

Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

June 16, 2021

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies.

January 23, 2008

The value from investments in health information technology at the U.S. Department of Veterans Affairs.

May 5, 2010

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

May 4, 2022

Adverse Events.

November 8, 2023

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

October 26, 2022

Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened.

July 12, 2006

VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.

July 5, 2006

VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.

July 5, 2006

Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.

January 31, 2006

Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety.

August 16, 2023

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

July 21, 2021

Addressing Health Worker Burnout.

June 8, 2022

Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.

April 5, 2017

Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic.

April 5, 2023

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

July 22, 2020

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs.

March 2, 2022

The State of VA Health Care.

October 1, 2014

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics.

October 30, 2019

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

November 15, 2023

Diagnostic Safety and Quality Webinar Series: Overview and Implications for Hospitals.

November 28, 2023 - November 28, 2023

PHSO Review: Quality of NHS Complaints Investigations.

June 22, 2016

Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: 2022 User Database Report.

November 9, 2022

Calibrate Dx: A Resource to Improve Diagnostic Decisions.

October 19, 2022

The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.

November 1, 2023

Controlled substance drug diversion by healthcare workers as a threat to patient safety.

March 14, 2023

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

February 15, 2023

Network of Patient Safety Databases Chartbook.

November 8, 2023

Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: User Database Report.

January 14, 2024

NPSD Data Spotlight: Patterns of Fall Interventions.

November 15, 2023

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

August 9, 2023

Related Resources

DOD Should Improve Its Process for Clinical Adverse Actions against Providers.

April 24, 2024

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

April 22, 2024

Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports.

April 16, 2024

Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures.

January 24, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

Reducing retained foreign objects in the operating room: a quality improvement initiative.

December 20, 2023

Patient Safety Structural Measure Specifications.

December 13, 2023

Adverse Events.

November 8, 2023

Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.

November 8, 2023

A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals.

November 1, 2023

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

Maryland Hospital Patient Safety Program Annual Report.

September 28, 2023

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers.

July 26, 2023

Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis.

July 12, 2023

Factors contributing to preventing operating room "never events": a machine learning analysis.

May 10, 2023

The high cost of retained surgical items.

April 26, 2023

Your Safety in our Hands in Hospital.

April 20, 2023

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

February 8, 2023

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work.

September 21, 2022

A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network.

August 17, 2022

Preventing retained surgical items.

August 3, 2022

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

May 4, 2022

Guideline for Prevention of Unintentionally Retained Surgical Items.

January 19, 2022

Agency information collection activities: National Healthcare Safety Network (NHSN); comment request.

October 13, 2021

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

October 7, 2021

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

August 20, 2021

See More About The Topic

Retained Surgical Instruments and Sponges

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site