Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

The safety culture of an operating room is known to affect teamwork and patient outcome. This article discusses the unique characteristics of robotic-assisted surgical practice and approaches teams and organizations can take to enhance communication that supports a safe care culture.

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.

Miscommunication between pathologists and surgeons can lead to significant patient harm. This study identified multiple discrepancies between pathologist-listed diagnoses included in intraoperative consult notes compared to surgeon-dictated operative notes. Discrepancies were most common in multipart cases and those involving deferrals.

Perioperative and anesthesia care present unique patient safety challenges. This article describes the development and implementation of the Anesthesia Risk Alert (ARA) program, which promotes collaborative clinical decision-making and recommends risk mitigation strategies to address specific high-risk clinical scenarios. Since implementation began in 2019, ARA compliance has exceeded 90% and has reduced the rate of adverse events among certain high-risk patients, such as those with a high body mass index.

Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.

Previous analyses have found that orthopedic surgery is one common source of patient harm. This survey of 305 orthopedists found that involvement in a medical malpractice lawsuit within the past two years increased the likelihood of experiencing burnout and reporting a medical error resulting in patient harm in the past year.

Systems involving people, tools, technology, and work environments must interact effectively to ensure the delivery of safe, effective care. This narrative review uses a sociotechnical perspective to explore the inter-relationship between technology and the human work environment during the delivery of anesthesia in the operating room. The authors discuss systems-level approaches, such as such as surgical safety checklists, as well as the role of resilience and new technologies (i.e., artificial intelligence).

Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.

Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.

Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.

Fatigue and sleep deprivation of anesthesia providers can result in decreased non-technical skills and psychomotor functioning. This study of 1,200 anesthesia and intensive care trainees in Europe describes the impact of work-related fatigue on well-being, commuting, and potential for medical errors. Two-thirds of respondents reported making or nearly making a medical error after working long hours. In addition to implementing shorter work schedules, the authors also encourage a culture where it is acceptable to admit fatigue, and where resting is encouraged.

The second victim concept encompasses an important concern for the impact of unsafe care on health care workers. This commentary discusses the topic and the need for system-level solutions to ensure surgical team members involved with patient harm due to errors can heal, and in doing so, provide safe care to their patients.

Human factors strategies are increasingly applied in health care to mitigate the impact of human error in medicine. This article discusses the use of checklists to systematize anesthesia and reduce risk in pediatric surgery.

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.