… safety efforts are sustainable in challenging times. … Fleisher LA, Schreiber M, Cardo D, et al. Health Care Safety during the Pandemic and Beyond - Building a System That Ensures Resilience.  N Engl J Med . …

Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.

Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.

… Ann Surg … Handoffs represent a vulnerable time for patients in which inadequate … In this prospective cohort study, researchers implemented a handoff protocol designed to improve handoffs between the … Standardization of the handoff process led to a decrease in omitted information and increased the length of …

Physician engagement in quality and safety improvement contributes to the sustainability of initiatives. This commentary describes how an academic health system engaged physicians in leading improvement efforts. The project encouraged use of local malpractice claims to design interventions and motivate physician involvement in quality improvement work.

… room to intensive care unit as well as the development of a standardized OR-to-ICU handoff protocol. …

When To Err Is Human was published, central line–associated bloodstream infections were considered an unavoidable patient safety problem. This commentary discusses how this mindset has changed over the past decade, citing the Keystone ICU project and other efforts that substantially decreased rates of this preventable hospital-acquired condition. The authors outline five elements that contributed to the reduction, including reliable and valid measurement processes, evidence-based care practices, and alignment around common goals and measures.

… behavior can hinder patient safety and create a disruptive work environment for other staff. The Joint … commentary describes the development and experience of a Professionalism Committee at the University of Pennsylvania … concerns. In this system, the committee chair is a trained psychiatrist, which the authors argue is an …

Antibiotics are among the most remarkable life-saving advances of modern medicine. However, when used incorrectly these medications pose serious risks for patients due to adverse effects and the potential to cause complicated infections, including those resistant to multiple antibiotics. This national database study found that more than half of all patients discharged from a hospital in 2010 received antibiotics during their stay. Many of these antibiotics were deemed to be unnecessary, and there was wide variation seen in antibiotic usage across hospital wards. A model accounting for both direct and indirect effects of antibiotics predicted that decreasing hospitalized patients' exposure to broad-spectrum antibiotics by 30% would lead to a 26% reduction in Clostridium difficile infection. The CDC recommends that all hospitals implement antibiotic stewardship programs, and this article provides core elements to guide these efforts. An AHRQ WebM&M commentary describes inappropriate antibiotic usage that resulted in a patient death. Dr. Alison Holmes spoke about infection prevention and antimicrobial stewardship in a recent AHRQ WebM&M interview.

This study discovered that nearly 70% of ambulatory surgical centers had at least one lapse in infection control. The most common lapses involved using a single-dose medication vial for more than one patient and failure to adhere to recommended practices for equipment handling.

Efforts to improve the care of complex patients in intensive care units (ICUs) focus on many factors, including unit-based initiatives. This retrospective study evaluated the relationship between daily multidisciplinary rounds and 30-day mortality. Investigators discovered that the presence of daily rounds was associated with lower mortality among medical ICU patients. In addition, the survival benefits observed with intensivist staffing were in part explained by the presence of multidisciplinary care models. A related commentary [see link below] discusses this study's findings and the concept of health engineering as a systems science to study how we optimize staffing and patient outcomes in the ICU.

This study found that adverse drug events from antibiotic use result in nearly 150,000 emergency department visits per year. An ultimately fatal case of an antibiotic adverse drug event is discussed in an AHRQ WebM&M commentary.

The investigators surveyed health care providers to determine their perceptions on patient safety in the health care system. They found that clinicians believed systemwide interventions and stronger patient involvement would improve safety.