… Br J Anaesth … Effective communication among providers helps … to patient injury in anaesthesia malpractice claims. Br J Anaesth. 2021;127(3):470-478. doi: 10.1016/j.bja.2021.05.030. …

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

The use of closed claims data to identify risk exposures, highlight safety issues, and drive improvement changes have been applied in ambulatory care, surgery, emergency medicine, and obstetrics. This study uses a previously described database to compare liability profiles in obstetric anesthesia before and after 1990. Investigators found that while the proportion of maternal death and newborn death or brain damage claims decreased in recent years (though still a leading cause), maternal nerve injury and back pain increased in later claims. Delays in anesthesia care, substandard care, and poor communication between the obstetrician and anesthesiologist are identified as preventable causes of newborn injury.

This study examines contributors to unexpected deaths in low-risk surgical patients, and concludes that patient and surgical factors were responsible for most deaths. The utility of examining unexpected deaths was discussed in a recent AHRQ WebM&M commentary.

… should be used only for screening purposes. An AHRQ WebM&M commentary discusses the limitations of using PSIs for …

The Patient Safety in Surgery study documented remarkable improvements in postoperative outcomes at Veterans Affairs hospitals following implementation of a quality improvement program. This study demonstrated similar improvement in clinical outcomes, including surgical site infection rates, following implementation of the program in private sector hospitals.

… Journal of the American College of Surgeons … J Am Coll Surg … Hospitals are urged to measure their safety …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … A cognitive aid was developed to assist …

Using closed malpractice claims from a previously described database, this study discovered significant patient injury associated with monitored anesthesia care (MAC) and a liability profile similar to that of general anesthesia. Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of general and regional anesthesia, and report on the claim characteristics. MAC claims involved older and more ill patients, with respiratory depression being the most frequent occurrence leading to patient injuries. The authors conclude that more than half of the claims would be preventable with improved monitoring strategies.

… and after specific practice guidelines were adopted. … Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. …