Examining strategies to reduce risk in anesthesia, this review discusses their limitations and suggests that better communication and teamwork can improve safety.

The results of a teamwork training program for operating room staff varied across professional specialty, with surgeons achieving the largest improvements in knowledge of safety and teamwork behaviors.

The so-called July phenomenon, in which errors are supposedly more common in July due to an influx of inexperienced residents and students, has long been a source of gallows humor in hospitals. Although prior studies have reached mixed conclusions, this Australian study of anesthesia errors did find a significant increase in preventable adverse events for procedures performed by trainees during the first 4 months of the academic year. Interestingly, error rates were higher for trainees at all levels, not just first-year residents. This finding implies that underlying systems issues as well as clinical inexperience resulted in adverse events. An accompanying editorial calls for revising training models in order to provide adequate supervision and support for new trainees. A case of inadvertent hypoglycemia resulting from an intern's lack of familiarity with insulin ordering at his new hospital is discussed in an AHRQ WebM&M commentary.

This review characterizes the various quality indicators used in anesthesia, and assesses the strength of the evidence supporting use of these indicators.

Teamwork and communication failures are a continuing threat to patient safety. Health care organizations have tried to integrate crew resource management (CRM) methods into focused training programs as a potential prevention strategy. While past studies have demonstrated benefits in emergency department settings, studies in the obstetric setting have shown both benefits and mixed results. This study adds to that literature by describing the experiences of participants after their involvement in a CRM intervention. Participants rated the course highly, expressed better knowledge of teamwork and shared decision-making, and also noted improved stress recognition. While patient outcomes were not measured, a positive change in the team and safety climate for the hospital was reported.

This cohort study, conducted in an Australian hospital, reports on the implementation of an incident reporting system within an existing anesthesia electronic medical record. Anesthesiologists were required to document any adverse events, in one of 16 predefined categories, as part of their routine clinical documentation. Acceptance of the system was high, and the vast majority of reported adverse events were confirmed by chart review. As prior research has shown that incident reporting systems suffer from low physician reporting rates, integration of incident reporting into routine electronic documentation may help increase physician reports of errors.

… more easily obtainable information from a medical chart. … Haller G, Myles PS, Wolfe R, Weeks AM, Stoelwinder J, McNeil J. Validity of unplanned admission to …