Healthcare Inspection Surgical Quality of Care Review Southern Arizona VA Health Care System Tucson, Arizona

The purpose of the review was to evaluate allegations that a surgical technician had performed tasks beyond the standards of practice, which placed patients at risk for severe injuries, and that operating room managers failed to take corrective actions at the Southern Arizona VA Health Care System. We substantiated that on one occasion a surgical technician placed two sutures to close a patient’s incision, a procedure that exceeded the technician’s standards of practice. There was no evidence the incident resulted in patient harm. We did not substantiate that managers failed to take corrective actions when they became aware of the incident. Managers were in the process of finalizing SOPs to address standards of practice for all non-physician surgery staff. We made no recommendations and plan no further actions.