Blood management errors can lead to serious patient harm. This article highlights five patient safety risks during pediatric perioperative blood management (failure to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative blood management, failure to consider specific intraoperative blood conservation techniques in children, failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion). The authors discuss potential solutions to address these safety risks.

Cognitive biases can influence treatment approach at the end of life. The goal of this study was to determine whether treatment approaches (e.g., palliative care to aggressive treatment) were associated with clinician cognitive biases in acute care settings for patients with advanced dementia and comorbidities. Representativeness, availability, and anchoring biases were associated with treatment approach in this hypothetical patient case; moral characteristics of the clinician were not associated with treatment approach.

Overlapping surgery, where “critical” portions of surgery are performed sequentially in separate operating rooms, is used to increase efficiency and number of procedures performed each day. This systematic review and meta-analysis was performed to determine differences in risk of complications between overlapping surgery (OS) and non-overlapping surgery (NOS) in total hip and total knee arthroplasty. Consistent with prior studies and reviews, there were no significant differences in adverse events or complications between OS and NOS. The authors stress that informed consent and patient education prior to OS is critically important.

Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.

This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims involving ambulatory surgery centers – dental injuries, pain, nerve damage, and death. The authors discuss the role of preoperative risk assessment, use of routine dental and airway assessment, adequate treatment of perioperative pain, and improving communication between patients and providers.

This article draws on interviews and observations to explore medical iatrogenesis in obstetric care. The authors discuss how various factors – such as universal management plans, labor and delivery interventions, and informed consent – contribute to iatrogenic harm and worse perinatal outcomes for racial/ethnic minority patients.

This study explored views, practices, and needs related to patient counseling on medication safety in obstetrics and gynecology. Survey responses from over 500 OB/GYNs indicate opportunities to improve available resources and information sharing, such as developing new tools to communicate about teratogenic medications and pregnancy-safe over-the-counter medications and dietary supplements.

This article discusses the challenges COVID-19 poses for shared decision making (such as physical distancing and health service reallocation, communicating uncertainty, delivering allergy/immunology care) and opportunities to evolve incorporation of shared decision making into clinical practice during and after the pandemic.

Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors. 

Ensuring safe, high-quality maternity care is a patient safety priority. This cross-sectional study of 2,138 women in the United States found that one in six women reported experiencing mistreatment during maternity care. Researchers found that women of color and women giving birth in hospitals (versus at home) were more likely to experience mistreatment. The most common forms of mistreatment were being yelled at or scolded by a health care provider, being ignored, violations of physical privacy, and threats to withhold treatment or being forced to accept treatment they did not want.

The process of informed consent is designed to ensure that patients fully understand risks, benefits, and alternatives when receiving certain treatments. In this mixed-methods study, researchers examined the impact of two Agency for Healthcare Research and Quality informed consent training modules across four hospitals.

By employing improvement science methods, a quality improvement initiative virtually eliminated surgical consent errors at a pediatric academic medical center.

Written consent forms often introduce issues related to legibility and completeness. A Web-based system for booking elective surgical procedures improved the rate of obtaining and documenting informed consent in a community hospital system.