While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.

Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.

Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.

In this qualitative study, researchers applied an organizational learning perspective to characterize the various approaches used by four Veterans Health Administration hospitals to determine their patient safety priorities.

… Am. J. Surg. … Am J Surg … In this study, researchers analyzed … and the hospital's incident reporting system. They found a positive association between the presence of intraoperative … conclude that using multiple sources of data provided a more comprehensive picture of safety during surgery. …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Reducing readmissions remains a major patient safety priority. Project Re-Engineered …

As outpatient surgery becomes more prevalent, attention around related safety concerns grows. Researchers analyzed postprocedure emergency department visits and hospital admissions to better understand factors associated with the safety of outpatient procedures performed within the Veterans Health Administration.

Readmissions occur frequently after hospital discharge and may reflect opportunities to improve the quality and safety of care provided during the index admission. Using a modified Delphi process, an expert panel reviewed 30-day postoperative readmissions over a 7-year period for patients who had received surgery within the Veterans Affairs system. The study suggests that more than 50% of postoperative readmissions may be related to the quality of surgical care provided during the index admission.

The Veterans Affairs Surgical Quality Improvement Program (VASQIP) and the private sector National Surgical Quality Improvement Program have transformed both safety measurement and quality in surgery. Historically, VASQIP has placed comparatively little emphasis on outpatient surgical safety. This study examined trends in hospital admission within 7 days of all outpatient surgeries performed among veterans age 65 and older in the United States. Researchers found that 16% of these procedures were associated with 7-day admission, higher than what has been observed in younger, healthier patients. Common reasons for admission included surgical, medical, or device complications and inability to secure safe aftercare at home. The authors posit that, while not every admission represents a preventable adverse event, measurement is a critical step toward improving outpatient surgical safety. A recent PSNet interview and perspective explored the evolution of surgical patient safety.

… J Patient Saf … J Patient Saf … This qualitative study asked surgical staff …

… American journal of surgery … Am J Surg … Decreased hospital staffing on nights and weekends has been associated with a greater risk of adverse outcomes. However, this study found …

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Inaccurate medication reconciliation … prescribing information. In this cluster-randomized trial, a pharmacist performed medication reconciliation with access … on medication reconciliation in the study. A past WebM&M commentary described how lack of access to prescribing …

… JAMA Surgery … JAMA Surg … Surgical site infections are a common hospital-acquired condition. This clinical guideline …

… Journal of the American College of Surgeons … J Am Coll Surg … Health care providers who experience … adverse event experienced negative emotions, and only a minority accessed formal support systems . This work …

Surgical site infections are a persistent and costly challenge to patient safety. These guidelines provide recommendations to reduce this common hospital-acquired condition, including policies for surgeon attire, hand hygiene, and equipment sterilization.

The AHRQ Patient Safety Indicators (PSIs) use hospitals' administrative data to measure quality and carry financial consequences for hospitals as part of pay-for-performance initiatives. Prior research has raised concerns about the validity of PSIs compared with directly using clinical data to identify safety events. AHRQ recently restructured PSI-90 (a composite measure containing multiple distinct PSIs) from volume-based to harm-based weighting. Using data from 132 Veterans Health Administration hospitals, this retrospective study compared hospital performance using the previous PSI-90 with performance under the redesigned measure. Although there was strong association between the volume-based and harm-based PSI-90 measures, use of the harm-based version had a significant impact on pay-for-performance because of changes in the weights of the component measures. Approximately 15% of hospitals in the study would face changes in financial penalties under the Hospital-Acquired Condition Reduction Program when using the new PSI-90. A past PSNet perspective discussed the impact of pay-for-performance.

Intraoperative adverse events have been shown to increase the risk of hospital readmission. In this study, investigators found that intraoperative adverse events during abdominal surgery were associated with increased postoperative mortality, morbidity, and length of stay.

… J Patient Saf … J Patient Saf … The Medicare Patient Safety Monitoring System … Patient Safety Monitoring System and its evolution into a new system that seeks to enhance the standardization and …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … High reliability organizations operate … patient safety largely matched their conceptual model of a high reliability health care organization and found two …

… Am. J. Surg. … Am J Surg … Hospital readmissions are an increasing focus of … with major intraoperative adverse events experienced a two-fold increase in readmission rates. …