Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.

Fentanyl is a high-risk medication, whether prescribed by a health professional or obtained illicitly. This patient safety advisory encourages healthcare providers to educate their patients on the risks of counterfeit fentanyl.

Some clinicians experience profound emotional distress following an adverse event, known as the “second victim” phenomenon. This study of surgical residents in the US found that most residents who reported being part of a medical error had subsequent emotional distress, including guilt, anxiety, and insomnia. Importantly, while three quarters of residents reported they did not get emotional support following the event, all those who did get support reported benefiting from it.

While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.

A key aspect of a robust safety culture is that all team members feel psychologically safe in difficult situations. This commentary describes the development and use of a speaking-up curriculum that focuses on communication skills, cultural expectations, cognitive restructuring techniques, and resilience strategies. The program successfully increased motivation and comfort of participants in sharing concerns in various clinical situations.

Wrong-patient and wrong-site surgeries are considered never events. This commentary describes a tool developed to decrease confusion in plastic surgery. The authors envision the tool to enhance team communication and preparation, which should reduce risk of wrong-site surgery.

Human factors perspectives can inform design and implementation of safety interventions in health care. This commentary summarizes the role of human factors engineering and checklists as safety improvement strategies in plastic surgery. The authors highlight nontechnical skill development, checklist customization, raising of concerns, and safety assessment as key areas of focus for the specialty.

This study found that encouraging patients to take skin biopsy selfies on smartphones may help patients and physicians more accurately identify the correct biopsy site for subsequent surgical excision, potentially avoiding wrong-site surgeries.

Implementation of the World Health Organization surgical safety checklist did not affect complication rates among plastic surgery patients at an academic medical center. Other studies have found similar disappointing results, the implications of which are discussed in a recent AHRQ WebM&M interview.

Disclosure and apology programs are recognized as elements of an effective organizational response to medical error. Using a case study involving an iatrogenic burn injury and disclosure, this review relates how three ethical principles apply to error disclosure.

Using AHRQ patient safety indicators, this study established that approximately 4% of plastic surgery patients experience an adverse event during their hospital stay. This rate is relatively low compared with other surgical disciplines, but it is significant due to the proportion of young healthy patients who undergo plastic surgery.

This commentary emphasizes the value of crew resource management and checklists in teamwork training programs to improve safety in surgical settings.

These articles review preoperative, intraoperative, and postoperative safety risks for plastic surgery patients and describe techniques to prevent adverse events.

This commentary outlines tactics to prevent complications in plastic surgery, including electronic medical records implementation and incident reporting.

Do resident physicians contribute disproportionately to medical errors? The evidence is mixed, despite the longstanding concern about a purported increase in errors in July, when most new residents start their training. This study compared complication rates in breast reduction surgery between surgical residents and an attending physician, and found no evidence of increased complications in procedures performed primarily by residents with close attending supervision. However, poor supervision of residents has resulted in substandard care in other settings.

This commentary describes the implementation of a proactive checklist to improve communication and ensure safety in the operative setting.

Patient safety in ambulatory surgery centers (ASCs) has received increasing attention, and the Joint Commission's National Patient Safety Goals now include specific requirements for ASCs. This study summarizes the types and severity of adverse events occurring in ASCs in Florida, gathered using that state's mandatory reporting system. The majority of deaths and hospital transfers occurred in patients undergoing cosmetic procedures, incidents that are generally considered never events. A previous AHRQ WebM&M commentary and perspective discuss the issues pertaining to improving safety in outpatient surgery, which remains a largely unregulated area.

This article reviews the unique risks when combining gynecologic and plastic surgery and offers strategies to optimize safety for these patients.

The authors review data on adverse events after outpatient surgical procedures in the state of Florida and discuss efforts to improve the safety culture within the field of plastic surgery.