Intraoperative deaths are rare, catastrophic events. This retrospective review of 154 intraoperative deaths occurring between March 2010 and August 2022 at one academic medical center found that most deaths occurred during emergency procedures. Common contributing factors included coordination challenges, skill-based errors, and environmental factors.

Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

… Diagnosis (Berl) … Clinical reasoning is now a common method to improve diagnostic decision making, and … specific, formative, and facilitated goal setting. … Cohen A, Sur M, Falco C, et al. Using the Assessment of Reasoning …

I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.

… among eight pediatric hospital medicine providers over a 12-month period. In the majority of cases, the diagnostic … led to the pursuit of alternative diagnoses. … Yale SC, Cohen SS, Kliegman RM, et al. A pause in pediatrics: implementation of a pediatric …

… toward improvement are discussed. … Kostick-Quenet K, Cohen I, Gerke S, et al. (2022). Mitigating racial bias in …

… and reported, the associated challenges, and proposes a new approach to reporting SAE/AE in clinical trials. A decision-tree to determine SAE/AE reporting based on the … approach is presented. … Baim-Lance A,  Ferreira KB, Cohen HJ, et al. Improving the approach to defining, …

A broad differential diagnosis can limit missed diagnostic opportunities. This article outlines how diagnostic timeouts, which are intended reduce bias during the identification of differential diagnoses, can improve diagnosis and reduce errors.

California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.

… in transitions of care, diagnosis, and care delays. … Cohen SP, McLean HS, Milne J, et al. Differences in safety …

… activity, spilling/dropping, teaching moment). … Boquet A, Cohen T, Diljohn F, et al. A theoretical model of flow disruptions for the anesthesia …

Designated safety leadership roles are situated to direct and sustain organizational safety progress. This commentary describes an anesthesiology safety officer function and how it is positioned to motivate staff safety behaviors and support engagement during project challenges.

… and unsafe acts threaten patient safety. … Wiegmann DA, L JW, T NC, et al. Understanding the "Swiss cheese model" and …

A key feature of safety culture is the psychological safety of all staff to feel empowered to speak up about errors or mistakes. In this study of intensive care unit clinicians, job strain, leader inclusiveness and perception of teamwork were associated with psychological safety. However, psychological safety was not associated with performance of either spontaneous breathing trials or lung-protective ventilation. Future research should focus on strategies to improve psychological safety in intensive care units.

While rare, surgical never events can have tragic consequences for patients including permanent harm and death. This study analyzed 142 surgical never events reported to the California Department of Public Health. Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site or wrong patient (15.5%), and surgical burns (7.7%). Recommended strategies to reduce and prevent never events include proper use of intraoperative checklists.

… increased the risk of ICU-acquired bloodstream infections: a case-cohort study from the multicentric OUTCOMEREA network. …