Department of Veterans Affairs 

Office of Inspector General 

Review of Patient Safety in the 

Operating Room in 

Veterans Health Administration Facilities 

Report No. 05-00379-91 February 28, 2007

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Review of Patient Safety in the Operating Room in VHA Facilities 

Contents 

Page 

Executive Summary ..............................................................................................i

Introduction...................................................................................................................... 1 

Purpose............................................................................................................................. 1

Background...................................................................................................................... 1

Scope and Methodology .................................................................................................. 3

Results and Conclusions ....................................................................................4

Issue 1: Compliance with VHA Directives, AORN Guidelines, and JCAHO 

 Standards....................................................................................................... 4

Issue 2: Surgical Performance Improvement Program............................................. 15

Issue 3: SPD Coordination with the OR................................................................... 19 

Comments....................................................................................................................... 22 

Appendixes 

A. Acting Under Secretary for Health Comments........................................................ 24

B. OIG Contact and Staff Acknowledgments............................................................... 38

C. Report Distribution................................................................................................... 39

VA Office of Inspector General 
Review of Patient Safety in the Operating Room in VHA Facilities 

Executive Summary 

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. Several environment of care issues needed management’s attention. The 

facilities did not collect, trend, and analyze patient related variance specific to the OR. 

The facilities did not properly document surgical resident supervision or disclose adverse 

events in the medical records. Mortality assessments were not consistent with VHA 

policy, and morbidity and mortality peer reviews were not completed for quality

improvement as required. Local policies did not clarify which OR providers require 

basic or advanced cardiac life support training. Lastly, we found that SPD was not 

consistently providing a continuous flow of processed sterile and non-sterile supplies, 

instruments, and equipment to the ORs. We made recommendations to address all of 

these issues. 

The Acting Under Secretary for Health agreed with our findings and recommendations

and provided appropriate action plans. We will follow up until all planned actions are 

completed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Acting Under Secretary for Health 

SUBJECT: Review of Patient Safety in the Operating Room in Veterans Health

Administration Facilities 

Introduction 

Purpose

The Department of Veterans Affairs, Office of Inspector General (OIG), Office of 

Healthcare Inspections conducted an evaluation of Veterans Health Administration 

(VHA) medical facility efforts to ensure patient safety in the operating room (OR). The 

purposes of this evaluation were 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.

Background 

In August 1998, the Joint Commission on Accreditation of Healthcare Organizations 

(JCAHO) issued a Sentinel Event Alert examining the problem of wrong site surgery, 

including a review of 15 cases that had been reported to them. The JCAHO sentinel

event database included 150 reported cases of wrong site, wrong person, or wrong 

procedure surgery, of which 126 had root cause analysis (RCA) information. Of the 126 

cases, 41 percent related to orthopedic/podiatric surgery; 20 percent related to general 

surgery; 14 percent to neurosurgery; 11 percent to urologic surgery; and the remaining to 

dental/oral maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic 

surgery. Seventy-six percent involved surgery on the wrong body part or site, 13 percent 

involved surgery on the wrong patient, and 11 percent involved the wrong surgical 

procedure. 

A search of the VHA National Center for Patient Safety (NCPS) Patient Safety 

Information System database (referred to as SPOT) for surgical procedures involving

VA Office of Inspector General 1 
Review of Patient Safety in the Operating Room in VHA Facilities 

retained sponges,1 revealed more than 70 cases, of which 58 percent were adverse events 

and 42 percent were close calls. The search covered the years 2000–2004. 

NCPS RCA data revealed 41 percent of cases had incorrect sponge counts; 21 percent 

were reported as correct; in 38 percent, no counts were documented. Sponges were left 

in the neck, chest, peritoneum, knee, groin, mediastinum,

2

 retroperitoneal cavity, and

pelvis. Gauze sponges have been discovered in a patient’s airway after a tracheostomy,3

 

defecated following use as a throat pack during a maxillectomy,4

 and found visibly 

extruding from an abdominal incision. Retained sponges were discovered before and 

after wound closure and were also found when searches were initiated after incorrect 

sponge counts were reported. In some cases, evidence of a retained sponge was not 

apparent until days, weeks, or years later, when x-rays were taken of patients with

symptoms of pain, swelling, or signs of occult infection. Radiologists also observed 

sponges in unrelated routine x-rays, and pathologists discovered them during autopsies. 

A 2004 report issued by VHA’s Office of Medical Inspector disclosed three patient 

incidents that occurred at a VA medical center (VAMC). The incidents involved a

retained surgical instrument, a retained surgical sponge, and an incorrect count. 

In August 2004, an OIG report cited incidents of missing instruments, wrong instruments,

broken instruments, and contaminated instruments at another VAMC.5

 The review found 

that SPD staff were unable to provide sterile equipment and needed supplies to the OR, 

resulting in the cancellation of 81 elective operations (37 in November 2003 and 44 in 

February 2004).6

The following information is presented to further explain the roles of the surgical staff. 

Surgeons, scrub nurses, surgical assistants, and surgical technicians are scrubbed in and 

wear sterile gowns, shoe covers, caps, and masks. The main duties of the scrub nurse or 

surgical techs include opening all sterile instrument packs, ensuring the right instruments 

are in the packs, organizing surgical instruments on the sterile field, handing the correct 

instrument to the surgeon, and doing needle and instrument counts at completion of the 

procedure. The nurse circulator (also known as the circulating nurse) is a registered

nurse who wears clean surgical scrubs, shoe covers, cap, and mask. However, the nurse 

circulator is not sterile and does not touch items or enter the sterile area of the operating 

room known as the sterile field. The nurse circulator’s main duties include assisting the 

surgeon, scrub nurse, or surgical assistants into their gowns and gloves, opening the

 1

 A sponge is a porous, absorbent mass, such as a pad of gauze or cotton surrounded by gauze. 2

 The region between the pleural sacs, containing the heart and all of the thoracic viscera except the lungs. 3

 A tracheostomy is an opening surgically created through the neck into the trachea (windpipe). 4

 Surgical removal of the maxilla, the major bone of the upper jaw. 5 Issues at VA Medical Center Bay Pines, Florida and Procurement and Deployment of the Core Financial and

Logistics System (CoreFLS), No. 04-01371-177, August 11, 2004. 6 Interim Report – Patient Care and Administrative Issues at the Bay Pines VA Medical Center, Bay Pines, FL, 

No. 04-0371-108, March 19, 2004. 

VA Office of Inspector General 2 
Review of Patient Safety in the Operating Room in VHA Facilities 

outside wrappings from sterile instrument trays, labeling specimen containers, keeping 

the sponge count, obtaining unexpected equipment/instruments, keeping the 

intraoperative nursing documentation records, and helping to escort the patient to the 

recovery room. 

The distribution area within SPD performs a major role in not only getting the correct

medical supplies and equipment to users, but also in assuring that these supplies are in the 

correct quantity, quality, location, and condition for use. More specifically, SPD is 

responsible for cleaning, wrapping, and sterilizing equipment for use in the OR and other 

areas. This allows clinical staff to focus their time and attention on patient care needs. 

Scope and Methodology 

The scope of this inspection included eight VHA medical facilities from October 3, 2005, 

through May 8, 2006. The eight facilities we visited represented a mix of facility size,

geographic location, and Veterans Integrated Service Networks (VISNs). We interviewed 

OR, SPD, Pathology and Laboratory Medicine Service, and infection control employees

and managers, as well as surgical quality managers, to determine if effective policies, 

procedures, and guidelines to ensure patient safety in the OR have been developed and 

implemented. 

We evaluated local policies, procedures, and guidelines for compliance with VHA/VA 

directives and handbooks, as well as Association of periOperative Registered Nurses 

(AORN) standards. We also examined committee minutes and surgical quality 

management reports and improvement plans to determine if trends and potential 

problems were identified and appropriate corrective actions implemented. 

We observed staff performing surgeries in the ORs to ensure that: 

• The correct surgery (right patient, procedure, and side) was performed. 

• Surgical counts (of sponges, sharps,7 and instruments) were conducted according to 

AORN standards. 

• Operating suite areas were environmentally clean and free of potential hazards (such 

as biological or pathological). 

We observed SPD areas to determine if SPD staff provided a continuous flow of 

processed sterile and non-sterile supplies, instruments, and equipment to all points of use. 

We conducted the evaluation in accordance with the Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency. 

 7

 Sharps are needles and other penetrating surgical instruments or any device having corners, edges, or projections 

capable of cutting or piercing the skin. 

VA Office of Inspector General 3 
Review of Patient Safety in the Operating Room in VHA Facilities 

Results and Conclusions 

Issue 1: Compliance with VHA Directives, AORN Guidelines, 

and JCAHO Standards 

Findings

It is VHA policy that in VHA facilities where surgery and invasive procedures are 

performed, specific steps must be implemented in order to reduce the likelihood of 

incorrect surgeries. VHA Directive 2004-0288

 provides specific information on what 

steps must be taken to ensure that the indicated surgical procedure was performed on the 

correct patient, at the correct site, and if applicable, with the correct implant. The five 

steps described in the directive are: 

• The consent form is administered and executed properly. 

• The operative site is marked. 

• The patient is actively identified using required techniques. 

• A “time-out” briefing9 is conducted in the OR prior to starting the surgical procedure. 

• Two members of the OR team review pertinent radiological images prior to 

commencing the surgical procedure. 

We found that six of the eight facilities (75 percent) had policies that, for the most part, 

paralleled the VHA Directive, while two facilities (25 percent) had polices that only 

addressed side/site verification. We found certain aspects of the directive had not been 

incorporated into the local policies. One facility did not have steps addressing actively 

identifying patients using the required techniques. Only two facilities (25 percent) 

addressed the requirement of staying with the patient (once identified) until the patient is

brought into the OR. Another facility did not have a written procedure whereby OR team 

members reviewed and verified radiological images. 

A. Ensuring Correct Surgery

In order to determine if the five steps identified in VHA Directive 2004-028 were

followed, we observed 88 various surgical procedures, including joint replacements, 

prostatectomies, colon resections, hernia repairs, cataract removals, craniotomies, 

hysterectomies, and open heart surgeries. 

 8 Ensuring Correct Surgery and Invasive Procedures, June 25, 2004. 9

 The time-out briefing is verification of the correct patient, correct procedure, correct site, and correct implant

(where applicable) by specific personnel in the OR prior to the start of the operation, and at a time when the patient

and required OR personnel are present in the OR. 

VA Office of Inspector General 4 
Review of Patient Safety in the Operating Room in VHA Facilities 

Step 1 – Informed Consent

We found that the facilities properly administered and executed the informed consent. 

However, we did observe an isolated incident where a nurse circulator wrote additional 

information on the consent form. The operation/procedure written on the consent form 

was “Left Clavicular Osteotomy.”10 The nurse circulator wrote “Left Rotator Cuff

Repair11 & Shoulder Decompression”12 on the consent form. The nurse informed the

patient the addition was further clarification of the surgical procedure. 

The nurse circulator initialed the change, but did not notify the attending surgeon of the 

changes to the consent form. The attending surgeon’s pre-operative note states the 

surgical procedure planned was “Left Shoulder Rotator Cuff Tear with Clavicular

Osteotomy.” The facility policy stated that if the consent form is incomplete or invalid, 

and if no emergency regarding the patient exists, the responsible practitioner will

postpone the procedure/treatment until a valid consent has been obtained. We informed 

management of the nurse circulator’s actions. 

Step 2 – Marking the Site

According to the VHA Directive, it is a requirement to mark virtually all operative sites, 

including those on the midline, face and groin. The directive allows for the use of a 

special-purpose wristband in cases where the site is awkward or problematic such as the

perineum. Most (75/88) facility surgeons or privileged providers marked the operative 

site or used special-purpose wristband as substitution for marking. However, at one 

facility, the patients were directed to mark their own operative sites, which was a direct 

violation of the VHA Directive. At this facility, we also observed the nursing staff mark 

the patient’s operative site. Furthermore, we observed a nurse write “yes” on the ace

bandage wrapped around a patient’s ankle (the patient was scheduled for removal of

hardware from his right ankle). After the ace bandage was removed in the OR, the 

operative site was left unmarked. The directive required that the mark be placed so that it 

will be visible in the operative field after the site is prepped and draped. 

At another facility, we observed that the operative site was not marked for a patient that 

had a radical retropubic prostatectomy. This facility also did not mark the site of patients 

undergoing open heart surgery, including the leg where the vein was harvested. 

Step 3 – Patient Identification

The nurse circulators were responsible for identifying patients prior to bringing them into

the OR. They asked the patients to verbally state their full name (84/88) and social

 10 The surgical cutting of a bone. 11 Re-attach the detached/torn rotator cuff muscle. 12 Make more space available for the tendons of the rotator cuff. Enlarging or “decompressing” the space between 

the acromion and the head of the humerus can relieve the symptoms of impingement. 

VA Office of Inspector General 5 
Review of Patient Safety in the Operating Room in VHA Facilities 

security number (81/88), and to identify the operative site (87/88). The patients’ 

responses were checked against the signed consent forms (69/88), the patients’ 

identification bands (87/88), as well as to the marked sites (76/88). 

The VHA Directive required that the patient state, not confirm this information. On 

several occasions (7/88) the patients were asked to state the last four of their social 

security number (SSN). We also observed an OR staff member ask an aphasic patient to

provide the required information (full name and SSN). The patient responded by saying 

“yes yes” and gesturing. The staff then asked him to confirm his unique information and 

the operative procedure and site. When ever possible, in cases where patients cannot

provide the correct responses themselves, another person with knowledge of the patient,

such as a family member, should be asked to state the name of the patient and the site to 

be operated on. The staff did not ascertain if the patient had someone with him to assist

with his identification. 

Several facilities implemented the iMedConsentTM13 software program. However, the 

facilities did not have portable or hand-held computers to access the consent form by 

which to compare the patient’s responses. While some facilities printed a copy of the 

consent and had it available during the identification process, others used a patient label, 

stamped with the patient’s name and SSN. 

We also observed incomplete patient identifications. Part of the identification process 

included verifying the marked site with the consent form. On a few occasions the nurse 

identified the patients even though the patients’ operative sites had not yet been marked. 

The patients were not re-identified until they were brought into the OR during the timeout briefing. 

The VHA Directive also stated that once the active identification is performed, the staff 

member who performed the identification must stay with the patient until the patient is 

transported into the OR. We only observed 78 percent (69/88) compliance. 

Step 4 – Time-Out Briefing

A time-out briefing is a final check prior to the start of the surgical procedure. We found 

that the facilities had procedures in place that require verification of the correct patient, 

the correct procedure, the correct site, and the correct implant (where applicable) by 

personnel in the OR prior to the start of the operation, and at a time when the patient and 

required OR personnel were present in the OR. During a time-out briefing, a designated 

member of the team verbally states the patient’s information. After the statement, other 

members of the team verbally state that they concur with this information before the 

procedure begins. At minimum, this process must include the surgeon, the nurse 

circulator, and the anesthesia provider. In most or many cases the patient will be under 

 13 iMedConsentTM is a patient-signed informed consent entered directly into the electronic medical record system. 

VA Office of Inspector General 6 
Review of Patient Safety in the Operating Room in VHA Facilities 

sedation or unconscious when the time-out briefing occurs and is not expected to 

participate in this process. 

Although the facility staff consistently performed time-out briefing (87/88), we found one 

facility that performed the time-out briefing shortly after the patient was brought into the

room and placed on the OR table. The patient was asked to state his name, SSN, and the 

procedure (including laterality, if applicable) to be performed. The patient’s responses 

were checked against his armband, but the responses were not checked against the 

consent form; and the marked site was not verified. 

At another facility, we also observed one incident when the surgical procedure was 

initiated prior to the time-out briefing. While observing a litholopaxy14 with transurethral 

resection of prostate15 (TURP), the surgeon dilated the patient’s urethra prior to the timeout briefing. Once the nurse circulator became aware that the surgeon had initiated the 

procedure, she immediately asked the surgeon to stop and called for the time-out briefing. 

At times, we found that all members of the OR team did not give their full attention to the 

time-out briefing. The nurse circulators had to solicit verbal concurrence from the 

surgeons or anesthesia providers. 

Step 5 – Imaging Data

We observed 27 (31 percent) procedures where physicians referred to pre-existing 

radiological images. Two members of the OR team were required to confirm that the 

images were correct, properly labeled (name and side of anatomy), and properly 

presented and oriented (right or left and up and down). We observed that two OR team

members inconsistently confirmed the radiological image simultaneously. The surgeon,

resident, and nurse circulator viewed the radiological image separately and we could not 

ascertain what elements of the image they reviewed. Nor did we see the two team 

members confirm with each other verification of the images. Furthermore, we found two 

images that were not appropriately labeled. In one case, the radiological image (left 

knee), which came from a community hospital, was not labeled with the side of the 

anatomy. In the second case (right ankle), we found no patient identifiers on the image. 

Nonetheless, the nurse circulators documented in the Intraoperative Report that the 

radiological images were appropriately verified 100 percent (27/27) of the time. 

B. Surgical Counts

At the start of our review, VHA did not have a directive addressing surgical counts; 

therefore, for purpose of this review, we used AORN recommended practices to 

determine compliance, as detailed in each section following. Individual facility surgical 

counts policy/procedure varied. Half of the facility policies did not address what surgical 

 14 Crushing stones in the bladder, followed by washing out the fragments. 15 Resection of the prostate by means of a cystoscope passed through the urethra. 

VA Office of Inspector General 7 
Review of Patient Safety in the Operating Room in VHA Facilities 

procedures would allow exclusion of instrument counts. All facilities with the exception

of one (12.5 percent) had a policy that addressed counting sharps (such as needles, 

blades, and bovie16 tips). Half of the local policies did not define what was a sponge or 

sharp. Nor did their policies provide guidance to the nursing staff when additional counts 

must be performed. We only found two facilities (25 percent) that addressed the 

sequence of surgical counts in their local policy. 

We reviewed the VHA Directive 2006-030, Prevention of Retained Surgical Items, dated 

May 17, 2006.17 The directive required that a written facility policy be in effect no later 

than June 30, 2006, which states that the surgical teams must take the necessary steps to

prevent the retention of foreign bodies from surgical procedures. These steps include 

surgical counts for all surgical procedures except for those where retention of a foreign 

body is virtually impossible (such as cataract extraction and diagnostic cystoscopy, as 

defined in the original directive dated April 3, 2006). Methods for counting instruments, 

sharps, and sponges must comply with the published 2005 standards of the AORN and 

AORN standards on the topic as directed by the VHA Director for Surgical Services. 

The directive also addresses what steps must be taken if any discrepancy in a count of a 

surgical item is discovered. 

Sponge and Sharps Counts

AORN guidelines recommend that sponges and sharps should be counted on all

procedures in which the possibility exists that a sponge or sharp could be retained. They 

advised that counts should be taken: 

• Before the procedure to establish a baseline. 

• Before closure of a cavity within a cavity. 

• Before wound closure begins. 

• At skin closure or end of the procedure. 

• At the time of permanent relief of either the scrub person or the circulating nurse.18 

We did find rare occasions where the sponge and sharp counts were not conducted as 

prescribed by AORN as follows: 

Count Not Taken Sponge Needle 

Before the procedure to establish a baseline 1 1 

Before closure of a cavity within a cavity 1 1 

Before wound closure 1 1 

At skin closure or end of the procedure 2 3 

 16 An instrument used for electrosurgical cauterization. 17 It rescinded VHA Directive 2006-030, Prevention of Retained Surgical Items, dated April 3, 2006. 18 AORN, Inc., Standards, Recommended Practices, and Guidelines, (2005). 

VA Office of Inspector General 8 
Review of Patient Safety in the Operating Room in VHA Facilities 

We observed four occasions when the counts were not performed when the scrub person 

or nurse circulator was permanently relieved. We also found one facility that performed

sponge and sharps counts before and after the lunch relief. 

AORN recommended that sponges should be separated, counted audibly, and

concurrently viewed during the count procedure by two individuals, one of whom should 

be a registered nurse circulator. Although this was generally practiced at all the facilities, 

the practice was inconsistent. The scrub person did not consistently separate sponges, 

particularly the laparotomy pads that were held together with retention bands. We also 

observed the nurse circulator add sponges and needles to the field, but they were not 

concurrently counted with the scrub person; however, the nurse circulator recorded the 

item(s) on the count board or count sheet. 

We observed two surgeries (orthopedic and neurologic surgeries) where the sharps counts 

were incorrect. In both cases, a needle was missing. The surgeons were informed of the 

incorrect count and attempts were made to find the missing needle. The nurse circulator 

and scrubbed person asked the surgeons to conduct manual searches of the wounds to 

locate the missing needles. The scrub person and nurse circulators did manual and visual

searches, respectively, of the sterile area surrounding the wound and the remainder of the

sterile field. The nurse circulators conducted searches of the nonsterile areas of the room 

in an attempt to locate the needle(s). Radiology was called to take an intraoperative xray. The needle in the orthopedic case was located prior to radiology arriving. The 

missing needle in the neurologic surgery was not detected on 

x-ray. The x-ray was read by the resident and the attending surgeon, not the radiologist. 

The nurse circulator initiated an incident report. 

Instrument Counts

Instruments should be counted for all procedures in which the likelihood exists that an 

instrument could be retained. AORN advised that counts should be taken: 

• Before the procedure to establish a baseline. 

• Before wound closure begins. 

• At the time of permanent relief of either the scrub person or the circulating nurse. 

Although half of the facilities delineated the surgical procedures that were exempt from 

instrument counts, we found that they did not always follow their own policy/procedure. 

Some facilities defined exceptions for instrument counts by listing the surgical 

procedures, while other used the size of the incision. Of the 88 surgical procedures we 

observed, 39 (44 percent) performed instrument counts. 

We found that one facility had a provision in their instrument count procedure that stated, 

“The scrub and circulating nurses perform the initial count, or they may BOTH agree to 

the count being done only by the scrub nurse.” We observed one case where the scrub 

VA Office of Inspector General 9 
Review of Patient Safety in the Operating Room in VHA Facilities 

person did the initial count alone. We were told that they had initiated this practice in

order to accelerate the baseline counting process. 

The facilities usually conducted the surgical counts after the patients were brought into 

the OR. However, we found at one facility, that they would not bring a patient into the 

OR until all counts had been completed. This allowed them to focus their full attention 

on the counting process without distractions. 

We found several instrument trays that contained an excessive number of instruments for 

the cases planned. Those instrument trays took longer to count and made it difficult to 

maintain an organized back table. The OR staff stated some of the orthopedic instrument

trays felt like they weighed over the 17 pound maximum recommended according to VA

policy.19 We found no scales in the OR suites. Three (37.5 percent) facility SPD 

sections did have a scale to weigh instrument trays, but they were not utilized. 

The new VHA Directive requires that all surgical instruments must be counted, except for 

procedures that are routinely concluded with a radiograph prior to closing the surgical 

wound (for example, an orthopedic case to assure proper alignment of a bone or implant). 

The directive also stipulated that: 

• Instrument sets are standardized with the minimum types and number of instruments 

needed for the procedure. 

• Preprinted count sheets that are identical to the standardized set be used for 

documenting counts. 

• Instruments counts are performed in the same sequence each time utilizing the

preprinted count sheet. 

C. Environment of Care

We generally found the eight facilities clean, the staff members motivated toward their 

job responsibilities, and staff demonstrated abilities to work well within a 

multidisciplinary team environment. Environmental and engineering staff members

generally followed VA directives and JCAHO standards. However, there was at times a 

lack of consensus on interpretation of JCAHO standards versus VA Central Office 

(VACO) directives. We found the following areas that needed improvement. 

 19 VA Handbook 7176, Supply, Processing, and Distribution (SPD) Operational Requirements issued 

August 16, 2002. 

VA Office of Inspector General 10 
Review of Patient Safety in the Operating Room in VHA Facilities 

Heating, Ventilation, and Air Conditioning

VHA design standards (2004) stipulate the four operational parameters for OR heating,

ventilation, and air conditioning (HVAC) systems as shown below: 

VHA OR-HVAC Design Criteria 

Air Changes/Hour (AC/H) 15 AC/H Minimum 

Room Pressurization Positive 

Relative Humidity (RH) 44 – 55 percent 

Temperature 62.6oF – 80.6oF 

We reviewed facility documentation of periodic testing of HVAC systems serving the OR 

environments. We found six facilities (75 percent) not in compliance with the JCAHO

standard.20 One facility had not had the HVAC system tested for over 5 years. A second 

facility recently completed an OR renovation, including the HVAC system, and had 

received a testing report from the contractor. The testing report identified two OR rooms 

that did not meet the 15 AC/H requirements.21 The facility elected to use both rooms for 

patient invasive (endoscopic) procedures. A third facility had recently completed an ORHVAC Certification Study and could not produce any prior studies for comparison or

review. The remaining facilities did not report complete HVAC performance data 

(temperature, humidity, AC/H, and positive pressurization) to the facility’s review 

committee and the governing body. Only two facilities provided data and committee

minutes documenting that they met this required testing. We could not locate VHA

guidance to field facilities concerning the department’s standard for OR-HVAC 

certification. 

Failure to adhere to OR-HVAC design criteria places patients in an environment lacking 

appropriate AC/H, temperature, and humidity conditions; compromises infection control 

measures; and could contribute to increased patient infection rates. 

 20 JCAHO criteria as described in the EOC Guidebook, 2005 Update (EC 1.7), specifically asks, “Is there a policy 

that describes how air filtration, air exchange and pressure relationships are maintained and tested in the following

areas: operating rooms, special procedure rooms, delivery rooms, negative isolation rooms, protective isolation

rooms, clinical laboratories, pharmacies and sterile supply areas? Are these tests performed and documented on a 

periodic basis?” 21 E-mail with VACO Clinical Engineering Section (McCrone & Safdie), September–October 2005.

VA Office of Inspector General 11 
Review of Patient Safety in the Operating Room in VHA Facilities 

Equipment Management

We reviewed the equipment records, preventive maintenance inspection (PMI) schedules, 

and equipment histories for OR equipment (such as anesthesia machine, operating table, 

cell saver, and portable x-ray machine) contained in the Engineering Service files.

Facility summaries are shown below: 

Equipment Type Total Facilities 

PMI 

Current 

Percent 

PMI 

Current 

Facilities 

PMI Not 

Current 

Percent PMI

Not Current 

Anesthesia machine 8 7 87.5% 1 12.5%

C-arm (portable x-ray machine) 7 4 57.1% 3 42.9%

Bovie (cauterizing machine) 8 7 87.5% 1 12.5%

Perfusion pump (heart-lung machine) 3 3 100% 0 0.0%

Cell saver 5 3 60.0% 2 40.0%

Operating table 8 4 50.0% 4 50.0%

Total 39 28 71.8% 11 28.2% 

For 28 percent (11/39) of the equipment items reviewed, we found facility equipment 

records incomplete, inconsistent, and an ineffective management tool to gauge the 

program’s safety, risk for patients, efficiency, and state of operational readiness. The 

data reviewed documented improper equipment in-processing, the assignment of specific 

PMI schedules, the completion of assigned PMI tests, and the completion of repair work

orders. 

Specifically our review found: 

• Personal Property Managers (PPM) did not properly in-process new and leased

equipment onto VA property. This was observed at all facilities. At one facility, 

vendors were observed entering the SPD while bringing in medical equipment that 

was not safety inspected and was out-of-date for recurring PMI inspection. The 

equipment was to be used in an ongoing operative procedure. 

• At six facilities (75 percent), PPM and engineering sections were not entering verified

information into the PPM and Automated Equipment Management

System/Mechanical Equipment Reporting System (AEMS/MERS) software programs 

to effectively account for and manage equipment accountability, PMI, and repair. 

• At six facilities (75 percent), PPM and engineering sections do not work in 

partnership to ensure equipment information is properly entered into each section’s

respective component within the AEMS/MERS software system. 

• At six facilities (75 percent), Engineering Service staff had not entered PMI 

information into the AEMS/MERS software package to properly prepare PMI 

VA Office of Inspector General 12 
Review of Patient Safety in the Operating Room in VHA Facilities 

schedules, PMI completed, PMI incomplete, and maintenance and repair work orders

for assigned equipment. 

The above findings affect the monitoring, validation, and verification of the safe 

operating capabilities and conditions of clinical equipment actively used on patients in 

the operating rooms on a daily basis. 

Anesthesia Medication Cart Security

At five facilities (62.5 percent), we found anesthesia medication carts unsecured during 

our inspections. We found the carts closed but the keys were still in the locks. We also

found filled syringes left on top of the carts unattended. OR employees assumed and

functioned with the understanding that the OR environment was a “secure” area. 

 

National Fire Protection Association Life Safety Code requires secondary egress from the 

OR area. Employees were observed using these egress pathways for routine exit as well 

as entrance, providing validation that unauthorized individuals can readily gain access to 

the OR and the vacant OR suites where various drugs and medications were available. 

Conclusions 

We found that most OR personnel followed the five steps outlined in VHA Directive 

2004-28. Some facilities marked the site only when laterality was involved. The use of 

iMedConsentTM software caused some logistical problems, making it difficult for staff to

compare the information provided by the patient against the consent form. 

The OR team members did not consistently stay with the patients after they had been

identified. Although nursing personnel documented verification of images, we did not

consistently see two OR team members confirm the radiological image simultaneously. 

Also, it was difficult to ascertain what elements of the images were reviewed. 

VA Office of Inspector General 13 
Review of Patient Safety in the Operating Room in VHA Facilities 

Individual facility policy/procedure for surgical counts varied. Nonetheless, revision of 

facility surgical count policy is required in order to comply with the new (May 17, 2006) 

VHA Directive 2006-030. 

Facilities surveyed were not testing the operation of the HVAC systems serving the OR 

areas and reporting the test results to a medical center standing committee. VHA does 

not have a policy or directive for field facilities that clarifies VHA interpretation of 

JCAHO standards for “periodic” OR-HVAC system certification. 

VAMC facilities were not effectively using computer-based software for the management 

of their clinical equipment. 

VAMC facilities were not monitoring medication cart security; they needed to ensure 

surgical service staffs secure anesthesia medication carts and that medications are in 

locked drawers or disposed of at the conclusion of each operative procedure. 

Recommended Action 1. We recommend that the Acting Under Secretary for Health, 

in conjunction with VISN and Medical Center Directors ensure that: 

(a) Local facility policy adheres to VHA Directive 2004-028 concerning: (i) confirmation 

of patient information against informed consent, (ii) staying with patients after they are 

identified and until they are brought into the OR, and (iii) verification of radiological 

images. 

(b) VHA Directive 2006-030 is implemented and monitored for compliance. 

(c) Healthcare Engineering disseminates to all field facilities VHA's interpretation of 

JCAHO's standard of “periodic” testing of OR-HVAC systems. Healthcare Engineering 

should consider the possibility of guidance that includes a suggested maximum interval 

to: (i) ensure field facilities review the operational testing data for OR-HVAC systems 

against the four operational parameters for OR-HVAC systems and (ii) results of the 

testing are reported to the appropriate standing committee and governing bodies. 

(d) Facility managers’ AEMS/ MERS information for clinically-based equipment items is 

complete and accurate. 

(e) Entry/Exit doors serving the OR suite, but not directly observable from the main OR 

entry area, should allow access only to authorized personnel to ensure the security of 

unattended medications, anesthesia carts, and OR equipment and supplies. 

VA Office of Inspector General 14 
Review of Patient Safety in the Operating Room in VHA Facilities 

Issue 2: Surgical Performance Improvement Program 

Findings

In general, the facilities inspected had comprehensive policies and procedures to follow

Quality Management and Patient Safety guidelines in the OR. However, we did not find

that the facilities collected, trended, and analyzed patient related variance such as surgical 

delays and cancellations, equipment or instrumentation problems, incorrect counts, return

to OR within 24-hours, medication problems, and other issues specific to the OR. Only 

two facilities had an OR Committee where these issues could be discussed and corrective 

actions developed to improve their surgical programs. 

We found that two facilities (25 percent) had incident or near miss incorrect surgery 

events in fiscal year (FY) 2005. The first facility reviewed the event of the wrong site 

surgery (right, instead of the planned left side inguinal hernia repair) and determined that 

(a) the surgeon did not possess the consent form when the site was marked, (b) the nurse

circulator did not mention the variance between the marked site and the consent, and (c) a 

time-out briefing with the informed consent was not performed. 

Based on the findings of their review, the following suggested improvements were made

to their Ensure Correct Surgery poster on display in the OR suite: 

• The operative site must be marked by a practitioner after reviewing the consent and in 

consultation with the patient. The enforcer of this step would be the nurse circulator, 

who will not take the patient back to the OR until the site is marked and in agreement 

with the consent. 

• Ownership of patient identification was assigned to the nurse circulator. The nurse 

circulator was also assigned responsibility to identify other documents, to include the 

attending note and the history and physical (H&P). 

• The ownership for the time-out briefing process was spelled out as follows: “within 

the OR when the patient is present and prior to beginning the procedure, the surgeon 

will call a time-out and the nurse circulator, anesthesiologist and surgeon will review 

for correct patient using the chart and the name band, proper positioning, proper 

marked site, procedure to be performed with the consent, and availability of the 

correct implant.” The enforcer of the time-out briefing was the scrub nurse or scrub 

technician who would not pass the necessary scalpel, scope, or other equipment if a 

time-out briefing had not been performed. 

For the most part, we observed that the corrective actions had been implemented and 

followed. However, this was the facility where the time-out briefing was not initiated 

prior to the TURP procedure. The scrub technician stated the surgeon removed the

instrument off the back table. Although the scrub technician did not pass the equipment 

VA Office of Inspector General 15 
Review of Patient Safety in the Operating Room in VHA Facilities 

to the surgeon, he did not inform the surgeon or nurse circulator that a time-out briefing 

had not been conducted. 

At the second facility, a patient had the wrong eye anesthetized (blocked). The nonoperative site was blocked by the surgeon. The incident was reviewed and monitors were 

developed and implemented to ensure the correct site was identified and marked. We

found no further incidents of near miss or wrong site surgery at the facility. 

We also found opportunities for improvement at several facilities in five of the following 

areas: 

Resident Supervision

VHA policy

22 requires that surgical residents treat patients within their scope of practice 

with proper supervision. Evidence of supervision is documented in one of four ways: 

(1) a supervising physician progress note, (2) a supervising physician progress note

addendum, (3) co-signature of the resident progress note by the supervising practitioner, 

or (4) a resident progress note documenting discussion with the supervising physician 

including agreement with the diagnosis and plan of treatment. We reviewed

documentation of selected records of 70 patients from a sample of 210 encounters that

involved Pre-Operative notes, H&P notes, and Brief Operative notes at seven facilities. 

One facility did not have a resident program. The results indicated: 

• Ninety percent (63/70) compliance with Pre-Operative notes. 

• Fifty-three percent (37/70) compliance with H&P notes. 

• One-hundred percent (68/6823) compliance with the Brief Operative notes. 

Disclosure of Adverse Events

VHA policy

24 requires prompt disclosure to patient and families about pertinent clinical 

facts associated with procedure errors, complications, or unexpected death related to

surgery or invasive procedures. The policy requires that the attending or senior 

practitioner or designee disclose the adverse events within 24 hours of the practitioner’s 

discovery of the event. We found that three (37.5 percent) facilities failed to document 

disclosure of adverse surgical events. The facilities did not disclose events involving 

retained foreign bodies, anesthesia block to the wrong surgical site, and unexpected 

deaths. All of these issues were considered reviewable Sentinel Events. A summary of 

some of the cases follows: 

 22 VHA Handbook 1400.1, Resident Supervision, July 27, 2005. 23 We found two patients who did not have a Brief Operative note in the medical record; thus changing the 

denominator. 24 VHA Directive 2005-049, Disclosure of Adverse Events to Patients, October 27, 2005. 

VA Office of Inspector General 16 
Review of Patient Safety in the Operating Room in VHA Facilities 

• At one facility, two patients had to return to surgery with partially retained drains. It 

was determined in both cases that the breaks occurred not from a defect in the drains

but from technical error. Only one patient’s medical record had documentation of the

patient being informed of the adverse event. However, the resident, not the attending 

surgeon, documented that he discussed the events with the patient and the need to

return to the OR to remove the drain. The second surgeries, in both cases, did not 

result in any further adverse outcomes. 

• At a second facility, the surgeon administered a regional block into the wrong eye. 

The procedure was aborted prior to initiating the surgery. We found no 

documentation that the patient had been informed about the adverse event. We also 

found that the facility did not document any disclosure of several unexpected deaths. 

In one case, the patient died in the OR. We found no documentation in the medical 

records that the events were discussed with the family. We did find a progress note, 

4 months after the death, addressing the complaints of the family member concerning 

frustration about their inability to obtain information. 

• In the third facility, we reviewed three surgery-related deaths that involved delay in

diagnosis or treatment. We obtained the medical records for review; in none of the 

cases did we find documentation of event disclosure. 

Morbidity and Mortality Peer Review

VHA policy25 requires all surgical mortalities and all major morbidities undergo peer

review, and Directive 2005-05626 requires that these reviews be done within 30 days of 

the original procedure. Five (62.5 percent) of the facilities visited had limited morbidity 

and mortality (M&M) conferences onsite. Instead, a majority of the patients were 

discussed at the affiliated university. The documentation of the conference was not 

shared with the VA facilities. 

One facility could not produce documentation of onsite M&M reviews. Also no records 

were available to indicate the required quality assurance data from any such reviews were 

used to help with performance improvement in the Surgical Service. 

One facility completed only 2 of 29 (7 percent) mortality reviews within the required 

timeframe of 30 days in FY 2005. Another facility reviewed only 7 of 32 (22 percent) 

mortalities. 

Mortality Assessment

VHA Directive 2005-056 requires that deaths be trended by facility, ward, service line, 

shift time, and provider. We found two of the facilities did not properly trend deaths in 

all required elements. One medical facility did not include shift time and provider; the 

 25 VHA Directive 2004-054, Peer Review for Quality Management, September 29, 2004. 26 VHA Directive 2005-056, Mortality Assessment, December 1, 2005. 

VA Office of Inspector General 17 
Review of Patient Safety in the Operating Room in VHA Facilities 

other did not have service line analysis. Trend analysis is necessary to evaluate 

potentially suspicious or unusual events. 

Credentialing and Privileging

A majority of the credentialing and privileging (C&P) files were well organized and 

contained the required documentation. VHA policy27 indicates that clinical staff working

in the OR may need Basic Cardiac Life Support (BCLS) and/or Advanced Cardiac Life 

Support (ACLS) certification in accordance with local committee policies. Four of the 

eight facilities had issues in this area. We reviewed 24 C&P files and found 6 providers 

with no certification and 2 with expired certification. Local policies were not always

clear regarding who required which type of certification. One facility had a policy in 

draft form only. 

Conclusions 

The facilities did not collect, trend, and analyze patient related variance specific to the 

OR. We concluded that facilities were not properly documenting surgical resident 

supervision or documenting disclosure of adverse events in the medical records. 

Mortality assessments were not consistent with VHA policy, and M&M peer reviews 

were not completed for quality improvement as required. We found that local policies 

did not clarify which OR providers require ACLS and BCLS training. 

Recommended Action 2. We recommend that the Acting Under Secretary for Health, 

in conjunction with VISN and Medical Center Directors, ensure that facility managers: 

(a) Encourage facilities to establish an OR/Invasive Procedures Committee that will 

collect, trend, and analyze patient related variance specific to the OR such as, but not 

limited to, adverse events and near misses, surgical delays and cancellations, equipment

or instrument problems, and incomplete and or incorrect operative consent. 

(b) Comply with VHA Handbook 1400.1 regarding documentation of surgical resident

supervision. 

(c) Comply with VHA Directive 2005-056 regarding mortality assessment. 

(d) Disclose and document adverse event discussion with patients and families in the 

medical records as required by VHA Directive 2005-049. 

(e) Initiate M&M reviews as required by VHA Directive 2004-054. 

 27 VHA Directive 2002-046, Staff Training in Cardiopulmonary Resuscitation and Advanced Cardiac Life Support, 

July 31, 2002, was in effect at the time of our review. 

VA Office of Inspector General 18 
Review of Patient Safety in the Operating Room in VHA Facilities 

(f) Delineate which OR providers require ACLS and BCLS training by: (i) implementing 

a system for monitoring the maintenance of ACLS or BCLS certification or training, 

(ii) determining where this information will be maintained and how it will be 

disseminated to staff who need to know of this qualification, and (iii) taking appropriate 

action to assure timely renewal of all certifications or the consequences if not maintained. 

Issue 3: SPD Coordination with the OR 

Findings

We assessed SPD operations to determine whether SPD provided a continuous flow of 

processed sterile and non-sterile supplies, instruments, and equipment to the ORs. We

found that SPD at two (25 percent) of the eight medical centers needed improvements in 

providing a more acceptable level of service to the ORs. Instrument trays and/or surgical 

case carts containing missing, broken, or incorrect instruments were issues at both 

facilities; one of the facilities experienced supply shortages and the OR receiving 

contaminated instruments. This occurred because quality control (QC) monitors were not 

effective, although they had been implemented in an effort to resolve the issues of 

missing, broken, or inaccurate instruments in instrument trays and surgical case carts. 

OR management at one facility attributed the problems to lack of knowledge on the part 

of the SPD staff; OR management at the second facility felt that SPD’s lack of attention

to detail led to the identified problems. We did not identify any adverse patient events

due to SPD issues, because OR staff ensured that the instruments were not contaminated 

and that all instrument trays and case carts contained the proper instruments prior to each 

surgery. 

Availability of Supplies

Medical supplies are expendable hospital, surgical, laboratory, and radiology items used 

in patient care and medical research. Medical supplies include such items as examination 

gloves, catheters, disposable scalpels and syringes, respirators, sutures, and x-ray film. 

We assessed the availability of surgical supplies to the ORs at eight medical facilities 

during this evaluation; we found that, except for isolated incidents at seven of the eight 

facilities, surgical supplies were generally available to the OR staff as needed. In some 

instances, the OR experienced minor delays while SPD located or borrowed supplies 

from an affiliated medical facility. 

At one of the eight facilities, the OR staff provided copies of e-mails between SPD and 

OR staffs that were used to report shortages of high-use items such as sterile drapes,

basins, gloves, and disposable towels. While not a daily occurrence, supply issues 

occurred often enough to produce a high level of frustration for the OR staff affected by

the shortages. However, based on the evidence we gathered, OR staff experienced only 

minor delays and no cancellations due to supply issues at the medical center. The OR 

VA Office of Inspector General 19 
Review of Patient Safety in the Operating Room in VHA Facilities 

staff managed “work arounds” for the supply issues, often substituting available items for 

the out-of-stock ones. 

Missing, Broken, and Incorrect Instruments

VA Handbook 7176, SPD Operational Requirements, dated August 16, 2002, states that

SPD is dedicated to the receiving, storage, and distribution of medical supplies. SPD

decontaminates and sterilizes reusable medical supplies and equipment to ensure a 

continuous flow of processed sterile and non-sterile supplies, instruments, and equipment

to all points of use. The distribution area of SPD performs a major role in not only 

getting the correct supplies and equipment to ORs but also in ensuring that these supplies 

are in the correct quantity, quality, location, and condition for use, allowing clinical staff 

to spend their time on patient care needs. 

At two of the eight medical facilities there were frequent occasions where instruments

were missing, broken, or incorrect. QC procedures that had been implemented to ensure 

that the proper instruments were in instrument trays at both facilities were not effective. 

QC monitors, as used by these facilities, are locally developed checklists. One employee 

lists the types of instrument trays or surgical case carts prepared and notes the date and 

time of preparation; a second employee checks the items in the tray or cart against a

checklist of required items for the noted surgical procedure and notes the date and time 

the check was completed prior to the tray or cart being sent to the OR. 

The QC monitors used at the two medical facilities to ensure the accuracy of instrument 

trays and surgical case carts were not effective. We were unable to determine the exact 

number of incidents because OR staff at both medical centers had stopped completing 

“Patient Incident Reports” and “Reports of Contact” for specific instances of missing, 

broken, or inaccurate instruments. OR staff stated that the reports were time consuming 

to prepare, and they had not been effective in resolving the problem. However, OR staff 

at both facilities provided us numerous e-mails documenting that they had notified the 

SPD Chiefs and the next level supervisors of these problems, but they were still 

experiencing the same problems. 

ORs experienced minimal surgical delays and no cancellations due to SPD issues, 

because the OR staff at both facilities ensured that all supplies and instruments were 

available and ready prior to each surgery. Some of the missing, broken, or incorrect 

instruments were general use items that OR staff could borrow from other trays or obtain 

from bins where extra supplies such as scissors, clamps, and sutures were maintained by

SPD in the OR areas. Other instruments were specialized and crucial to the performance 

of particular procedures. For example, the OR staff at both medical centers reported that

scopes required for laparoscopic procedures were often sent to the ORs with mismatched 

parts. The scopes were acquired from three different suppliers; if the pieces from the 

different vendors were interchanged, the scopes could not be used. 

VA Office of Inspector General 20 
Review of Patient Safety in the Operating Room in VHA Facilities 

In November 2004, one facility instituted a Daily Tray Preparation Inspection monitor 

that required two SPD employees to inspect the instrument trays and certify that the trays

were complete and accurate before sending them to OR. (OR staff there prepared the 

case carts as they needed them with instrument trays and supplies furnished by SPD). 

However, OR staff were still experiencing problems with missing, broken, and incorrect 

instruments in the trays SPD prepared. We observed OR staff prior to upcoming 

surgeries opening instrument trays with missing, broken, or incorrect instruments, even 

though both SPD employees had signed the count sheets signifying that the QC reviews 

had been performed. There were no patient care issues because OR staff always ensured 

that they had the proper instruments prior to each surgery. 

At the other medical center, SPD had implemented a QC monitor to verify whether case 

carts were complete and accurate before the carts were sent to OR. A QC procedure had 

not been implemented for instrument trays. However, we still found that surgical case 

carts and instrument trays sent to OR had missing, broken, or incorrect instruments. Our 

survey of 25 OR, Anesthesia, and Surgery Service staff members resulted in 22 (88 

percent) of the respondents stating that SPD was not providing an acceptable level of 

service to the OR. 

Contaminated Surgical Instruments

Contaminated items from the OR enter the SPD decontamination area in covered 

containers. Once in the decontamination area, surgical instruments must be inspected for 

tissue or bone fragments remaining in the teeth or grooves of the instruments. This debris 

is to be removed by holding the instrument under the surface of the cleaning solution and

scrubbing the area with a specifically-designed tool. All items are to be cleaned and 

disinfected before leaving the decontamination area. 

At one of the two medical centers with missing, broken, or incorrect instruments, we 

identified three occasions where OR staff received instrument trays with contaminated 

instruments that had to be returned to SPD for decontamination and sterilization before 

they could be used. No adverse patient incidents occurred, because OR staff ensured the 

instruments were not contaminated prior to each surgery. The three incidents occurred in 

August 2005 within a few days of each other; after the third incident of the OR receiving 

“dirty” instruments, SPD implemented a QC procedure to monitor the decontamination 

process. One SPD employee logs in and inspects the surgical instruments for tissue or 

bone fragments remaining in the teeth or grooves of the instruments before they are 

decontaminated; and a second employee inspects the instruments after they have been

sterilized. Both employees initial the QC checklist. OR staff confirmed there had been 

no subsequent incidents since the QC monitor was implemented. 

VA Office of Inspector General 21 
Review of Patient Safety in the Operating Room in VHA Facilities 

Conclusion 

VA Handbook 7176 states that the major goal of SPD is to allow the professional medical

staff every opportunity to concentrate on direct patient care. SPD optimizes its support of 

the medical facility by ensuring a continuous flow of processed sterile and non-sterile 

supplies, instruments, and equipment to all points of use. We found that SPD at two 

medical centers were not providing this level of service to the OR. In addition, one of the 

sites was regularly experiencing supply shortages of high use items like gloves and sterile 

drapes. Although QC procedures had been implemented to ensure the accuracy and 

completeness of instrument trays and case carts, the corrective actions were not effective. 

As a result, OR staff continued to receive instrument trays and case carts with missing, 

broken, or incorrect instruments that were crucial to the scheduled surgeries. We did not

identify any adverse patient events due to SPD issues, because OR staff ensured that the 

instruments were not contaminated and that all instrument trays and case carts contained 

the proper instruments prior to each surgery. 

Recommended Action 3. We recommend that the Acting Under Secretary for Health

ensures that SPD provides a continuous flow of processed sterile and non-sterile supplies, 

instruments, and equipment to the ORs.

Comments 

We inspected eight different VA medical facilities between October 3, 2005 and May 8, 

2006, using VHA directives, AORN guidelines, and JCAHO standards. As a result of 

this review, we made recommendations that: 

• Local facility policies adhere to VHA Directive 2004-028, Ensuring Correct Surgery 

and Invasive Procedures. 

• VHA Directive 2006-030, Prevention of Retained Surgical Items, is implemented and 

monitored for compliance. 

• VA Central Office – Clinical Engineering clearly defines and disseminates to all field 

facilities VHA’s interpretation of Joint Commission on Accreditation of Healthcare 

Organization’s standard of “periodic” testing of OR-heating, ventilation, and air 

conditioning systems. 

• Information for clinically-based equipment items is complete and accurate. 

• Entry/Exit doors serving the OR suite, but not directly observable from the main OR

entry area, should allow access only to authorized personnel. 

• Compliance with VHA Handbook 1400.1, Resident Supervision, regarding 

documentation of surgical resident supervision. 

• Compliance with VHA Directive 2005-056, Mortality Assessment, regarding 

mortality assessments. 

VA Office of Inspector General 22 
Review of Patient Safety in the Operating Room in VHA Facilities 

• Disclosure and documentation of adverse event discussions with patients and families 

in the medical records as required by VHA Directive 2005-049, Disclosure of Adverse

Events to Patients. 

• Initiation of morbidity and mortality reviews as required by VHA Directive 2004-054, 

Peer Review for Quality Management. 

• Each facility should clearly delineate which OR providers require advanced cardiac 

life support and basic cardiac life support training. 

• SPD provides a continuous flow of processed sterile and non-sterile supplies,

instruments, and equipment to the ORs. 

The Acting Under Secretary for Health agreed with our findings and recommendations

and provided a detailed action plan addressing each recommendation, with a goal of 

improving policy implmentation and compliance monitoring. (See Appendix A, pages 

24–37 for the full text of the comments.) 

The proposed actions are appropriate and responsive to the recommendations. We will 

follow up on the planned actions until they are completed. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 23 
Review of Patient Safety in the Operating Room in VHA Facilities 

Appendix A 

Acting Under Secretary for Health Comments

Department of 

Veterans Affairs Memorandum

Date: December 21, 2006 

From: Acting Under Secretary for Health 

Subject: OIG Draft Report, Review of Patient Safety in the 

Operating Room in Veterans Health Administration

Facilities, Project No. 2005-00379-HI-0048 (WebCIMS 

367759) 

To: Assistant Inspector General for Healthcare Inspections

(54) 

1. I have reviewed the draft report and concur with the

recommendations. Patient safety in the operating room (OR) 

is an important clinical issue, and the report cites valuable 

opportunities for improvement that need to be addressed. I 

was, however, pleased with your acknowledgement that the 

majority of Veterans Health Administration (VHA) OR 

personnel follow the steps described in VHA Directive 2004-

028, Ensuring Correct Surgery and Invasive Procedures. As

an organization, we work diligently to provide a consistent 

and high level of patient care in the OR by taking the 

necessary steps to ensure that the indicated surgical procedure 

is performed on the correct patient, at the correct site, and if 

applicable with the correct implant. I believe continued 

reliance on and adherence to the steps laid out in VHA 

guidance is an important component of maintaining a safe 

operating room environment, and all VHA facilities need to 

consistently comply with the standards. 

2. To this point, your report highlights the lack of

consistency across the reviewed facilities in complying with 

the pertinent VHA and Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) standards. I share your

concern that VHA needs do a better job of ensuring that local 

facility policies adhere to and reflect a standardized 

VA Office of Inspector General 24 
Review of Patient Safety in the Operating Room in VHA Facilities 

interpretation of national policies and required JCAHO

elements. A major component of realizing this

standardization is improving policy implementation and 

compliance monitoring. To this end, VHA’s Office of the

Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) will work with the National Center 

for Patient Safety and the Office of Patient Care Services, 

National Director of Surgery to further reinforce the elements 

of VHA Directive 2004-028 and VHA Directive 2006-030, 

Prevention of OR-Retained Surgical Items. The National 

Director of Surgery will further share the report's findings and 

reinforce adherence to these Directives with the surgical 

quality boards including the National Surgical Quality 

Improvement Program, Continuous Improvement in Cardiac

Surgery Programs, and the Neurological Surgery Board. OIG

Draft Report, Review of Patient Safety in the Operating

Room in Veterans Health Administration Facilities, Project 

No. 2005-00379-HI-0048 (WebCIMS 367759) 

3. On the topic of surgical counts, it is important to note

that while VHA did not have a directive addressing surgical 

counts at the beginning of your review, we issued VHA 

Directive 2006-030, Prevention of OR-Retained Surgical

Items, on May 17, 2006. Although you used Association of 

Perioperative Registered Nurses (AORN) recommended 

practices to determine compliance for surgical counts in your 

review, I want to highlight the fact that VHA's new Directive 

goes beyond AORN standards in two important ways: 1) it

requires that a methodical wound exploration precede closing 

the patient; and 2) it requires that in cases where there is a 

discrepancy in a counted items (e.g., sponge, instrument, or

sharp), a radiograph must be obtained within 30 minutes to

help determine if the discrepant count is actually associated 

with a retained surgical item. 

4. VHA has also increased expectations for supervision 

of resident physicians in the last five years. With issuance of 

VHA Handbook 1400.1, Resident Supervision, VHA clarified

and strengthened requirements outlining an expanded 

presence of supervising practitioners, proper documentation 

of resident supervision, and implementation of local 

monitoring processes and procedures for specific clinical 

settings. Additionally, in 2004, VHA designed and 

VA Office of Inspector General 25 
Review of Patient Safety in the Operating Room in VHA Facilities 

implemented a national performance measure that monitors

the timeliness of supervising attending admission notes for 

medicine, psychiatry, and surgery. Subsequent results for this 

performance measure show impressive improvement in 

timeliness over the last two years. Such progress not

withstanding, this review of patient safety in the OR, as well 

as your recently-released draft report, Review of Resident

Supervision Documentation and Billing Practices in Veterans 

Health Administration Facilities, find ample opportunities for 

improvement in documentation of surgical resident

supervision. 

5. In regard to your findings, I think it is necessary to 

clarify that both reviews took place during a period of time 

when compliance with requirements for resident supervision 

documentation were rapidly changing. Although this review, 

which concluded on May 8, 2006, states that inpatient surgery 

compliance for the resident supervision performance measure 

was only 53 percent, VHA's 3rd Quarter, FY 2006 national 

performance measure reflects a markedly improved 

compliance rate of 86 percent. While I agree that the report's 

low compliance rate for inpatient surgery is indicative of the 

need for improvement at the eight facilities you inspected, I 

believe our improving national performance measure data, 

which utilizes the External Peer Review Program to analyze a 

large data set of over 30,000 medical records per year, is 

evidence that VHA is making significant system-wide 

progress. Nonetheless, I was pleased with your findings that

VHA is substantially compliant (90 percent) with preoperative note requirements and 100 percent compliant with 

the brief operative note guidelines. In order to maintain this

trend of improvement, VHA will continue all current OIG 

Draft Report, Review of Patient Safety in the Operating

Room in Veterans Health Administration Facilities, Project 

No. 2005-00379-HI-0048 (WebCIMS 367759) measures to 

enhance resident supervision and resident supervision 

documentation. 

6. Lastly, I fully agree that Supply, Processing, and 

Distribution (SPD) should provide a continuous flow of

processed sterile and non-sterile supplies, instruments, and 

equipment to the operating room. To this end, VA does have

in place SPD Handbook 7176, SPD Operational

VA Office of Inspector General 26 
Review of Patient Safety in the Operating Room in VHA Facilities 

Requirements, identifying that SPD performs a major role in 

getting the correct supplies, instruments, and equipment to 

users and assuring that these items are in the correct quantity, 

location, and condition for use. The VA also has SPD 

Quality Assurance tools and other resources and training in 

place to assist field facilities. The issues involved in 

providing SPD support to end users, especially the operating 

room, are complex. They involve, for example, close 

coordination between SPD, the end users and vendors. With 

surgical care, there can also be unanticipated cases which 

impacts SPD’s and other’s ability to provide timely, quality 

support to the operating room which is dependent on each 

field facility’s local circumstances. Efforts have and will 

continue to be made with the National Surgical Office, 

National Operating Room Manager’s Workgroup, and the 

DUSHOM's Office, among others, to ensure continuous 

improvements in activities that involve SPD support, 

especially to the OR. 

7. Attached is VHA’s complete plan of corrective action,

which provides a summary of specific initiatives that I believe 

appropriately address identified issues in the report. Thank 

you for the opportunity to review the draft report. If you have

any questions, please contact Margaret M. Seleski, Director, 

Management Review Service (10B5) at (202) 565-7638.

 (original signed by:)

Michael J. Kussman, MD, MS, MACP 

Attachment

VA Office of Inspector General 27 
Review of Patient Safety in the Operating Room in VHA Facilities 

Acting Under Secretary for Health Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response 

to the recommendation(s) in the Office of Inspector General’s 

Report: 

OIG Recommendation(s)

Recommended Action 1. We recommend that the 

Acting Under Secretary for Health, in conjunction with VISN

and Medical Center Directors ensure that: 

(a) Local facility policy adheres to VHA Directive 2004-028 

concerning: (i) confirmation of patient information against 

informed consent, (ii) staying with patients after they are 

identified and until they are brought into the OR, and (iii) 

verification of radiological images. 

Concur Target Completion Date: 6/30/2007 

VHA Directive 2004-028, issued May 17, 2006 requires 

facilities to have a written policy in effect to address what 

steps must be taken to ensure that the indicated surgical or 

invasive procedure is performed on the correct patient, at the 

correct site, and if applicable with the correct implant. It also

addresses necessary steps surgical teams must take to prevent 

the retention of foreign bodies during surgical procedures. 

On June 2, 2006, the Deputy Under Secretary for Health for 

Operations and Management (DUSHOM) distributed a memo

to the Network Directors and Chief Medical Officers (CMO) 

reinforcing the elements of this Directive. 

DUSHOM will work with the National Center for Patient 

Safety, the Office of Patient Care Services, National Director 

of Surgery, and the Office of Nursing Service to further 

reinforce the elements of this Directive, pertaining to (i) 

confirmation of patient information against informed consent; 

(ii) staying with patients after they are identified and until 

they are brought into the operating room (OR); and (iii) 

verification of radiological images, during CMO conference 

VA Office of Inspector General 28 
Review of Patient Safety in the Operating Room in VHA Facilities 

calls, monthly conference calls with all Chiefs, and with OR 

managers. The Office of Patient Care Services, National 

Director of Surgery will further share the report's findings and 

reinforce the elements of the Directive with the surgical 

quality boards including the National Surgical Quality 

Improvement Program, Continuous Improvement in Cardiac

Surgery Programs, and the Neurological Surgery Board as 

agenda action items for reinforcement. 

The National Center for Patient Safety will work with the 

Office of Patient Care Services, National Director of Surgery 

and the Office of Nursing Services to develop a checklist for 

use at the facility and/or network level that will facilitate the 

review of local policies for the purposes of establishing 

conformance with the national policy contained in VHA

Directive 2004-028. DUSHOM will then distribute the 

checklist to the field with the opportunity for facility and/or 

network level staff to ask key VA Central Office program

office staff questions regarding the checklist. 

Additionally, informed consent workflow analysis and reengineering was a large part of the iMedConsentTM

implementation guidance. The issues identified in the draft 

report indicate that the sites reviewed have not re-engineered 

their clinical workflow in the OR suite to account for the need 

to verify consent forms as outlined in VHA Directive 2004-

028. The National Center for Ethics in Health Care is 

updating this guidance for re-release to help sites find and 

address pre- and post-implementation challenges such as

those observed by the OIG. After, the National Center for 

Ethics in Health Care gains concurrence, it will work with 

DUSHOM to distribute and reinforce the updated guidance. 

This revised guidance will include requirements regarding 

training for appropriate staff in all specialty areas in the use of 

iMedConsentTM by local clinical application coordinators as 

well as completion of informed consent workflow analysis for 

every specialty in which iMedConsentTM is (or will be) 

deployed. 

VA Office of Inspector General 29 
Review of Patient Safety in the Operating Room in VHA Facilities 

(b) VHA Directive 2006-030 is implemented and monitored 

for compliance. 

Concur Target Completion Date: 6/30/2007 

To reinforce the elements of VHA Directive 2006-030,

VHA's National Director of Surgery and Director of Policy 

and Clinical Affairs presented a briefing on Patient Safety in

the Operating Room, Prevention of Retained Surgical Items

to VHA CMOs on November 27, 2006. Likewise, the Office 

of Patient Safety and the National Director of Surgery 

presented a briefing on Ensuring Correct Surgery Data to 

VHA CMOs on October 16, 2006. These presentations were 

also provided to the VHA National Patient Safety Managers 

in May, 2006. 

Furthermore, the DUSHOM will work with the National 

Center for Patient Safety and the Office of Patient Care 

Services, National Director of Surgery to further reinforce the 

elements of this Directive to ensure implementation and 

monitoring for compliance during CMO conference calls, 

Monthly Conference Calls with all Chiefs, and with OR 

managers. The Office of Patient Care Services, National 

Director of Surgery will further share the report's findings and 

reinforce the Directive with the surgical quality boards 

including the National Surgical Quality Improvement 

Program, Continuous Improvement in Cardiac Surgery 

Programs, and the Neurological Surgery Board as agenda

action items for reinforcement. 

The Office of Patient Safety will work with the Office of 

Patient Care Services, National Director of Surgery and the 

Office of Nursing Services to develop a checklist for use at 

the facility and/or network level that will facilitate the review

of local policies for the purposes of establishing conformance 

with the national policy contained in VHA Directive 2006-

030. DUSHOM will then distribute the checklist to the field 

with the opportunity for facility and/or network level staff to 

ask key VA Central Office program office staff questions

regarding the checklist. 

VA Office of Inspector General 30 
Review of Patient Safety in the Operating Room in VHA Facilities 

(c) Healthcare engineering disseminates to all field facilities, 

VHA's interpretation of JCAHO's standard of “periodic” 

testing of OR-HVAC systems. Healthcare Engineering 

should consider the possibility of guidance that includes a 

suggested maximum interval: (i) ensure field facilities review 

the operational testing data for OR-HVAC systems against 

the four operational parameters for OR-HVAC systems, (ii)

results of the testing are reported to the appropriate standing 

committee and governing bodies. 

 Concur Target Completion Date: 3/1/2007 

The Office of Healthcare Engineering will seek JCAHO's 

intended meaning of the word "periodic" in their standards. 

Once this clarification is provided, Healthcare Engineering 

will review and consider whether maximum intervals should 

be established. When a determination is made, Healthcare 

Engineering will make an announcement on the National 

Engineering Conference Call to cover VHA's interpretation of 

JCAHO's standard of “periodic” testing of Operating Room – 

Heating, Ventilation, and Air Conditioning systems, as well 

as guidance on review and reporting of operational testing 

data. In addition, Healthcare Engineering will post the 

updated guidance on the Center for Engineering and 

Occupational Safety and Health web site. 

(d) Facility managers’ AEMS/ MERS information for 

clinically-based equipment items is complete and accurate. 

Concur Target Completion Date: 2/16/2007 

The Office of Healthcare Engineering will make an 

announcement reminding the field of its responsibilities on 

the National Engineering Conference Call. Healthcare 

Engineering will advise field units to review their existing 

policies to ensure that standard operating procedures are 

adequate, and that local reminders may be needed to improve

compliance. 

(e) Entry/Exit doors serving the OR suite, but not directly 

observable from the main OR entry area, should allow access 

only to authorized personnel, to ensure the security of 

VA Office of Inspector General 31 
Review of Patient Safety in the Operating Room in VHA Facilities 

unattended medications, anesthesia carts, and OR equipment 

and supplies 

Concur Target Completion Date: 2/28/2007 

VHA will form a multi-disciplinary task force to include, but 

not limited to, representatives from the DUSHOM, Office of 

Patient Care Services, Anesthesia Service, and the Office of 

Nursing Services, to develop VHA’s position and determine 

how to distribute guidance to the field. 

Recommended Action 2. We recommend that the Acting 

Under Secretary for Health, in conjunction with VISN and 

Medical Center Directors, ensure that facility managers: 

(a) Encourage facilities to establish an OR/Invasive 

Procedures Committee that will collect, trend, and analyze 

patient related variance specific to the OR such as, but not

limited to, adverse events and near misses, surgical delays 

and cancellations, equipment or instrument problems, and 

incomplete and or incorrect operative consent. 

Concur Target Completion Date: 2/28/2007 

VHA Program offices including the Office of Patient Care 

Services, National Director of Surgery, the Office of Quality 

and Performance (OQP), the National Center for Patient 

Safety, the Office of Nursing Services, and the Office of the 

DUSHOM will assure that this recommendation is

communicated to all VHA networks and facilities. VHA 

facilities will have the option to assign this duty to existing 

committees that review processes and outcomes of care such 

as Morbidity and Mortality committees or to establish new 

committees to assure that local issues related to surgery and 

invasive procedures are identified and addressed. 

In addition, the Office of Patient Care Services, National 

Director of Surgery will brief CMOs and Chiefs of Surgery 

on conference calls, by memorandum, and as part of quality 

VA Office of Inspector General 32 
Review of Patient Safety in the Operating Room in VHA Facilities 

improvement programs associated with the National Surgical 

Quality Improvement Program and Continuous Improvement

in Cardiac Surgery Programs to help establish these 

committees at each facility. The Office of Patient Care 

Services, National Director of Surgery will further promote 

the need to collect, trend, and analyze patient related variance 

specific to the OR during quality site visits and action plan

reviews. 

(b) Comply with VHA Handbook 1400.1 regarding 

documentation of surgical resident supervision. 

 Concur Target Completion Date: On-going 

As the OIG's report shows, VHA is substantially compliant 

(90 percent) with pre-operative note requirements and 100 

percent compliant with the brief operative note guidelines. 

Similarly, VHA's 3rd Quarter, FY 2006 national performance 

measure for inpatient surgery (H&P notes) compliance 

reflects a high compliance rate of 86 percent. As VHA's 

improved performance measures can attest, it is clear that 

resident supervision documentation compliance is increasing 

rapidly system-wide. These improvements are a direct result 

of Resident Supervision Handbook 1400.1's precise 

requirements for all facilities to monitor six specific 

components of clinical care: 1) inpatient care; 2) outpatient 

care; 3) consultative care; 4) emergency department; 5)

operating room (OR) procedures; and 6) non-OR procedures.

Subsequently, VHA will continue all current measures to 

enhance resident supervision and resident supervision 

documentation. 

(c) Comply with VHA Directive 2005-056 regarding 

mortality assessment. 

 Concur Target Completion Date: 6/30/2007 

The OQP will discuss the importance of complying with the 

Mortality Directive at national CMO/Quality Management 

Officer meetings or conference calls. Specific policies will 

VA Office of Inspector General 33 
Review of Patient Safety in the Operating Room in VHA Facilities 

be reinforced regarding the reporting of all deaths by facility, 

ward, service line and provider (when a specific provider can 

be linked to the care of specific patients). OQP will obtain 

examples of compliant mortality trending reports created at 

the facility level through the System-wide Ongoing 

Assessment and Review Strategy program and/or by 

contacting selected facilities. OQP will share these templates 

during the aforementioned meeting and upload them to its 

website. 

The Office of Patient Care Services, National Director of 

Surgery will support this initiative by reiterating the criteria 

and guidance for this Directive as required through 

communication with all Surgical Service Chiefs and quality

review groups. 

(d) Disclose and document adverse event discussion with 

patients and families in the medical records as required by 

VHA Directive 2005-049. 

 Concur Target Completion Date: 3/30/2007 

The Office of the DUSHOM will schedule time on the 

Thursday Network Director call, Friday Hotline call, CMO 

calls, and Chief Surgical Officer calls to emphasize that VA 

providers and facilities must appropriately disclose adverse 

events to patients harmed in the course of their care in VA. 

DUSHOM will use examples of non-disclosure identified by 

the OIG in its report to illustrate the discussion. 

VHA Directive 2005-049 is currently under revision. Upon 

re-issuance of the policy, the National Center for Ethics in 

Health Care will schedule a National Ethics Teleconference 

to inform the field about the revisions and address 

misconceptions about the obligation to disclose and document

adverse event discussions with patients and families in the 

medical records as highlighted by this and other OIG reports. 

(e) Initiate M&M reviews as required by VHA Directive 

2004-054. 

 Concur Target Completion Date: 6/30/2007 

VA Office of Inspector General 34 
Review of Patient Safety in the Operating Room in VHA Facilities 

The OQP is forming a new committee, which includes the 

Office of Patient Care Services, the Office of the Medical 

Inspector (OMI), Network Directors, CMOs, Quality 

Managers, and Facility Directors, among others, to review the 

current peer review policy (VHA Directive 2004-054). This 

review will include the following topics mentioned in the 

OIG's report: timing of death reviews, documentation of onsite reviews, and sharing of documentation of reviews

conducted off-site at affiliated universities. The purpose of 

this committee will be to develop approaches to address the 

deficits identified in the report. Additionally, OMI has been 

conducting surveys on peer review, and OQP will use survey 

results to further assess local review of deaths. 

Additionally, the Office of Patient Care Services, National 

Director of Surgery and the Office of the Deputy Under

Secretary for Operations and Management will redistribute 

guidelines for Morbidity and Mortality reviews to all Chiefs 

of Surgery and Chiefs of Staff. The Office of Patient Care 

Services, National Director of Surgery will seek evidence of 

these reviews during all site visits for the Surgery Quality 

Boards, including: National Surgical Quality Improvement 

Program, Continuous Improvement in Cardiac Surgery 

Programs, and Neurosurgery Quality Board. 

(f) Delineate which OR providers require ACLS and BCLS 

training by: (i) implementing a system for monitoring the 

maintenance of ACLS or BCLS certification or training, (ii) 

determining where this information will be maintained and 

how it will be disseminated to staff who need to know of this 

qualification, (iii) taking appropriate action to assure timely 

renewal of all certifications or the consequences if not

maintained. 

Concur Target Completion Date: 6/30/2007 

VHA Directive 2002-046, Staff Training in Cardiopulmonary

Resuscitation and Advanced Cardiac Life Support, dated July

31, 2002 states, “the medical center director is responsible for

ensuring that the facility Cardiopulmonary Resuscitation 

VA Office of Inspector General 35 
Review of Patient Safety in the Operating Room in VHA Facilities 

Committee determines which staff will be required to 

maintain current Advanced Cardiac Life Support (ACLS) 

certification.” The directive also states, “Certain clinical staff

may need to have current ACLS certification if, for example, 

they work in the Coronary Care Unit or Emergency Room

(see subpar. 4b), or Operating Room, even if they are not

participants in the code team.” 

The Office of Patient Care Services will work with the Office 

of Deputy Under Secretary for Operations and Management 

to ensure that information regarding ACLS and Basic Cardiac 

Life Support certification are considered as part of a process 

at each facility that defines scope of practice policy for 

operating room providers. Each facility will implement and 

maintain a policy to ensure compliance. 

Recommended Action 3. We recommend that the Acting 

Under Secretary for Health ensures that SPD provides a 

continuous flow of processed sterile and non-sterile supplies, 

instruments, and equipment to the ORs. 

Concur Target Completion Date: On-going 

VHA developed the National Supply SPD Quality 

Management Observational Assessment Tool because of the 

occurrence of multiple issues relating to cleaning, 

decontamination, and sterilization of patient care medical 

devices. At the national level, the Office of Patient Care 

Services, Chief Consultant for Infectious Disease will analyze 

the results of this survey, which was just completed in 

October 2006, and work with the Office of the Deputy Under 

Secretary for Operations and Management to guide future

national education and mitigation efforts. At the network and 

facility level, the findings will provide a status report of 

current operations and opportunities for improvement as 

needed. 

System-wide Ongoing Assessment and Review Strategy 

(SOARS) program teams also use two different assessment 

guides developed specifically for review of SPD and the OR. 

All VHA facilities undergo a SOARS site visit at least once 

VA Office of Inspector General 36 
Review of Patient Safety in the Operating Room in VHA Facilities 

every three years. Additionally, VHA selected SPD as one of 

the Self Assessment and Improvement in High Risk areas for

the FY07 VHA Monitoring activities. Each facility will 

complete a self assessment using the SOARS assessment 

guide during the First Quarter, FY07. 

VA Office of Inspector General 37 
Review of Patient Safety in the Operating Room in VHA Facilities 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact Marisa Casado, Director 

Regional Office of Healthcare Inspections 

St. Petersburg, FL

(727) 395-2416 

Acknowledgments Charles Cook 

David Griffith 

Reba Ransom

Michelle Porter 

Yolonda Johnson 

Elizabeth Butler 

Beth Bullock 

Jeff Joppie 

VA Office of Inspector General 38 
Review of Patient Safety in the Operating Room in VHA Facilities

Appendix C 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Veterans Benefits Administration 

National Cemetery Administration 

Assistant Secretaries 

Office of General Counsel 

Directors, Veterans Integrated Service Networks (1–23)

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Oversight and Government Reform

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 39