Clinical Areas

Browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nursing or medical specialty, featured in the resources.

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WebAIRS Anesthesia Incident Reporting System.

Australian and New Zealand Tripartite Anaesthetic Data Committee.

Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website serves as a secure mechanism for submitting incident reports to a centralized... Read More

NPSD Data Spotlight: Patterns of Fall Interventions.

Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0055.

Falls are a frequently reported sentinel event. This Data Spotlight from AHRQ’s Network of Patient Safety Databases (NPSD) highlights the most common interventions in place among patients who... Read More

Intravenous (IV) push medications – bridging the gap between education and clinical practice.

ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent... Read More

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

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines... Read More

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Anesthesia workspaces for safe medication practices: design guidelines.

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MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.

Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.

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Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.

Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

Handoff tool improves transitions from the operating room to the neonatal intensive care unit.

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Gallois JB, Zagory JA, Barkemeyer B, et al. Pediatr Qual Saf. 2023;8:e695.

Structured handoff tools can improve situational awareness and patient safety. This study describes the development and implementation of a bespoke tool for handoffs from the operating room to the neonatal intensive care unit (NICU). While use remained inconsistent during the study period, the goal of 80% compliance was achieved and 83% surveyed staff agreed or strongly agreed that the handoff provided needed information, up from 21% before implementation.

Sentinel Event Alert 68: Updated surgical fire prevention for the 21st Century.

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Jt Comm J Qual Patient Saf. 2023;Epub Oct 18.

Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.

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

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Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available.

On Patient Safety.

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Rickert J, Järvinen TLN, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet?

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Roy JM, Rumalla K, Skandalakis GP, et al. Neurosurg Rev. 2023;46:227.

Failure to rescue (FTR) quality metrics measure the ability of healthcare teams and hospitals to prevent mortality following a major complication. This systematic review included 12 studies and examined how FTR has been used in neurosurgical populations. The authors discuss several modifications to existing FTR definitions to better suit neurosurgical patients, such as incorporating measures of baseline frailty.

Delay in Malignancy Diagnosis Reflects Systemic Failures.

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WebM&M Case October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

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

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

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

Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR.

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Ramjaun A, Hammond Mobilio M, Wright N, et al. Ann Surg. 2023;278:e1142-e1147.

Situational awareness is an essential component of teamwork. This qualitative study examined how situational awareness and team culture impact intraoperative handoff practice. Researchers found that participants often assumed that team members are interchangeable and that trained staff should be able to determine handoff appropriateness without having to consult the larger operating room team – both of these assumptions hinder team communication and situational awareness.

MHA and MHA Keystone Center Annual Reports.

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Okemos, MI: Michigan Health & Hospital Association.

This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. The achievements noted in the 2022-2023 data review include reduction of MHA Keystone Center PSO members have significantly reduced both fall and blood or blood product events reported to the state patient safety organization reporting system. Areas of focus for improvement work reported on include health equity, workforce wellbeing, and maternal health.

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity.

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Moyal-Smith R, Etheridge JC, Turley N, et al. BMJ Qual Saf. 2023;Epub Sep 21.

Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.

Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

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Bagian JP, Paull DE, DeRosier JM. Surg Open Sci. 2023;16:33-36.

The Accreditation Council for Graduate Medical Education (ACGME) requires post-graduate education to include patient safety curriculum. This article describes the development and evaluation of a curriculum for residents on patient safety investigations using the Root Cause Analysis and Action (RCA2) model. Residents were surveyed at least one year after completion of the training. Sixty-three percent of respondents agreed or strongly agreed residents should be provided with the RCA2 training and nearly half reported having participated on an RCA team since completing the program.

Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study.

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Teigné D, Cazet L, Birgand G, et al. Int J Qual Health Care. 2023;35:mzad069.

Interruptions and distractions can diminish the quality and safety of care and lead to preventable medical errors. This observational study characterized interruptions affecting 23 care teams working in medical or surgical specialties across 17 sites in France. The researchers estimated that, on average, professionals were interrupted 10.5 times per hour, and that 57% of interruptions were avoidable.

Perioperative team-based morbidity and mortality conferences: a systematic review of the literature.

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Samost-Williams A, Rosen R, Hannenberg A, et al. Ann Surg Open. 2023;4:e321.

Morbidity and mortality conferences offer important opportunities for healthcare teams to discuss adverse events, learn from errors, and improve patient safety. This systematic review examined beneficial aspects of perioperative team-based morbidity and mortality (TBMM) conferences. The authors found that TBMM conferences generally led to improvements in patient safety, quality improvement, and educational outcomes and that certain factors (case preparation, standardized presentation format, effective facilitation) increase TBMM benefits.

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions.

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Ryan AN, Robertson KL, Glass BD. Int J Clin Pharm. 2023;Epub Sep 9.

Look-alike medications can cause confusion and contribute to medication administration errors. This scoping review including 18 articles identified several risk reduction strategies to mitigate look-alike medication errors in perioperative settings, such as improved labelling and standardization of storage. The authors note that further research is needed to assess the effectiveness of technology-based solutions, such as automated dispensing cabinets.

Addressing bias in acute postoperative pain management.

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Harbell MW, Maloney J, Anderson MA, et al. Curr Pain Headache Rep. 2023;27:407-415.

Provider bias may impact the pain management patients receive post-operatively. This review presents recent findings on the types and amounts of pain management patients receive. Results suggest women and people of color receive less pain medication despite reporting higher pain scores. Results regarding socio-economic status and English language proficiency bias are mixed. Implicit bias training, prescribing guidelines for all patients, and culturally competent pain management scales have all been suggested as ways to reduce provider bias and improve pain management.

Surgeons' leadership style and team behavior in the hybrid operating room: prospective cohort study.

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Soenens G, Marchand B, Doyen B, et al. Ann Surg. 2023;278:e5-e12.

Leadership style can dramatically impact the culture of safety. This analysis of video-recorded endovascular procedures found that surgeons’ transformational leadership style (e.g., motivation/enthusiasm, individual consideration, emphasis on the collective mission) positively impacts team behaviors such as speaking up behaviors and knowledge sharing.

Standardization and visualization of the surgical time-out.

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Levy BE, Wilt WS, Lantz S, et al. J Patient Saf. 2023;19:453-459.

The surgical time out is an effective strategy to reduce errors and improve team communication but full team participation remains a challenge. This article describes a Plan, Do, Study, Act project of developing and implementing a white board time out checklist to encourage all operating room personnel to participate. A significant increase in the number of completed time out items was seen after implementation.

Fire safety in the operating room.

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Ehrenwerth J. UptoDate. September 27, 2023..

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.

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