The operating room is a high-risk environment involving complex tasks. This study used cognitive task analysis (CTA) to explore how anesthesia nurses and anesthesiologists manage complex everyday situations during intraoperative care processes. Findings underscore the importance of available resources, team composition, and non-technical skills (NTS) for managing complex daily work and promoting patient safety.

Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This qualitative study characterized the role of front-line ICU managers in organizing for safe care and creating a culture of safety.  

… diagnostic errors . … Fernholm  R, Holzmann MJ, Wachtler C, et al. Patient-related factors associated with an …

… errors and its importance in patient safety. … Fernholm R, Pukk Härenstam K, Wachtler C, Nilsson GH, Holzmann MJ, Carlsson AC. Diagnostic errors …

This Swedish pediatric surgery team employed crew resource management training, which included checklists, communication training, and workflow redesign. The pre–post analysis showed sustained improvements in safety culture, checklist adherence, communication quality, and unplanned returns to surgery after laparoscopic appendectomy. Although this study design cannot control for secular trends, few crew resource management analyses include patient outcomes or such lengthy follow-up.

This comparison of two different methodologies for retrospectively detecting safety events found that the methodology used in the Harvard Medical Practice Study was more accurate than that used in the Global Trigger Tool.

Public reporting of quality measures is now widely used as a means of spurring hospitals to invest in patient safety and quality improvement efforts; however, it remains unclear if reported measures truly indicate a higher quality of care. In this study of more than 400,000 patients, researchers analyzed the relationship between adherence to recommended measures to prevent postoperative surgical infections and the subsequent development of such infections. They found that infection rates decreased only when all recommended interventions were carried out; performance of individual interventions did not seem to affect infection rates. Checklists—a relatively simple tool to ensure that all recommended steps of a process are carried out for every patient—initially gained fame as a means of preventing central line infections, and have subsequently been demonstrated to reduce surgical site infections.

Drawing on parallels between organisms and organizations, the authors advocate that clinicians collaborate with biomedical scientists to learn about complex systems and improve patient safety management.

The authors discuss the pilot of a tool that infuses systems thinking concepts into patient safety education. Their results suggest that the process increased student awareness of patient safety issues.