Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Additional Filters
1 - 20 of 156
Adams-McGavin RC, Jung JJ, van Dalen ASHM, et al. Ann Surg. 2021;274(1):114-119.
Resilience is the process of identifying and overcoming unexpected adverse events. By reviewing video, audio, and patient physiologic data recorded during 24 laparoscopic surgeries, researchers were able to identify safety threats and resilience supports used to overcome them. Of the six category codes, (person, task, tools and technology, physical environment, organization, and external environment) most safety threats and supports were in the person category.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132(6):1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.  
Cramer JD, Balakrishnan K, Roy S, et al. OTO Open. 2020;4(4):2473974X2097573.
Various surgical specialties have implemented surgical checklists to improve patient safety outcomes. In this survey of 543 otolaryngologists, surgical safety checklists were widely used, but intraoperative adverse events continue to occur. The most common adverse events reported were medication errors, wrong site/patient/procedure events, and retained surgical items.

Odor PM, Bampoe S, Lucas DN, et al the Pan-London Peri-operative Audit and Research Network (PLAN), for the DREAMY Investigators Group. Anaesthesia. Epub 2021 Jan 12.

Accidental patient awareness during anesthesia can result in significant patient distress and harm. This prospective cohort study, including 3,115 patients, identified high rates of accidental awareness during general anesthesia for obstetric surgery. In some patients, accidental awareness resulted in distressing experiences, paralysis, or a provisional diagnosis of post-traumatic stress disorder.
Kolodzey L, Trbovich PL, Kashfi A, et al. Ann Surg. 2020;272(6):1164-1170.
Health systems weaknesses can hinder safe patient care. Based on recordings of complex laparoscopic general surgery procedures, this qualitative study identified both safety threats and resilience supports across multiple systems engineering categories. Safety threats associated with the physical environment (e.g., workspace design/setup), tasks, organization (e.g., unsafe staffing), and equipment (e.g., unclear instructions) were most common. Resilience supports were primarily attributed to clinician behaviors.  

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.  

Labeling mistakes in the pharmaceutical production cycle can remain undetected until the affected medication reaches a patient. This alert reports a recall of a neuromuscular blocker for use in surgery due to it being mislabeled as a medication to increase blood pressure. 
Althoff FC, Wachtendorf LJ, Rostin P, et al. BMJ Qual Saf. 2020;30(8):678-688.
Prior research suggests that patients undergoing surgery at night are at greater risk for intraoperative adverse events. This retrospective cohort study including over 350,000 adult patients undergoing non-cardiac surgery found that night surgery was associated with an increased risk of postoperative mortality and morbidity. The effect was mediated by potentially preventable factors, including higher blood transfusion rates and more frequent provider handovers.
Gui JL, Nemergut EC, Forkin KT. J Clin Anesth. 2020;68:110110.
Distractions and interruptions are common in health care delivery. This literature review discusses the range of operating room distractions (from common events such as “small talk” to more intense distractions such as unavailable equipment) that can affect anesthesia practice, and their likely impact on patient safety.
Arriaga AF, Szyld D, Pian-Smith MCM. Anesthesiol Clin. 2020;38(4):801-820.
Debriefing is an established strategy teams use to learn from critical events, reduce event occurrence, and improve failure response. This review examines how debriefing principles can be embedded for use of the practice in real time, rather than developed in simulated circumstances, to improve anesthesia safety.

Hannenberg AA, ed. Anesthesiol Clin. 2020;38(4):727-922.

Anesthesiology critical events are uncommon, and yet they have great potential for harm. This special issue focuses on management of, and preparation for, perioperative critical events and rescue should they occur. The authors highlight simulation training, debriefing, and cognitive aids as methods for improving safety in the operating room.
Boet S, Djokhdem H, Leir SA, et al. Br J Anaesth. 2020;125(4):605-613.
Handoffs between providers can introduce patient safety risks. This systematic review explored the impacts of intraoperative anesthesia handovers (e.g., intraoperative relief, transferring care to an incoming provider) on patient safety outcomes. The researchers pooled four studies and found that an intraoperative anesthesia handover significantly increases the risk of an adverse event by 40%.
Dell-Kuster S, Gomes NV, Gawria L, et al. BMJ. 2020;370:m2917.
This cohort study enrolled 18 sites across 12 countries to assess the validity of a newly developed classification system (ClassIntra v1.0) for assessing intraoperative adverse events. Results indicate that the tool has high criterion validity and can be incorporated into routine practice in perioperative surgical safety checklists or used as a monitoring/reporting tool.
Dekker - van Doorn C, Wauben LSGL, van Wijngaarden JDH, et al. BMC Health Serv Res. 2020;20(1):426.
This study explored whether combining participatory design and experiential learning supports the adaptation and adoption of TOPplus, which is a communication tool to support and improve communication and teamwork among the operating room team. Adaptation varied amongst the ten participating Dutch hospitals, but all implemented the intervention with all surgical disciplines, and this approach gave teams the opportunity to adapt the intervention to fit their needs and local context. 
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2019-June 2020, reported pressure ulcers increased while treatment delays and surgery-related events decreased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving team communication and use of hospital data to reduce delays.
Wæhle HV, Haugen AS, Wiig S, et al. BMC Health Services Research. 2020;20.
This qualitative study examined how perioperative teams integrate surgical safety checklists into daily surgical practice and existing risk management strategies.  Perceived usefulness was the primary factor associated with use (69%); nurse anesthetists and anesthesiologists were more likely than other provider types to express that their existing safety protocols were sufficient and that elements of the checklist are redundant. The perception of usefulness was found to have considerable impact on checklist execution and communication, and the tool is most effective when it is an integrated part of the multidisciplinary risk management strategy.
Bloom JP, Moonsamy P, Gartland RM, et al. J Thorac Cardiovasc Surg. 2019.
This study examined whether increased team turnover raises the likelihood of sharp count errors by surgical teams and negatively affects patient outcomes. Analyses of all cardiac operations performed at Massachusetts General Hospital over a 5-year period revealed that sharp count errors were associated with higher rates of in-hospital mortality and were more prevalent with increased team turnover and on weekends. A prior Web M&M commentary discusses adverse outcomes arising due a retained foreign object during cardiac surgery.
Pugh CM, Law KE, Cohen ER, et al. Am J Surg. 2020;219(2):214-220.
Using a human factors engineering framework, this study reviewed video of residents performing a simulated hernia repair to identify and characterize errors, error detection and error recovery. The twenty participating residents made 314 errors; the majority were technical errors (63%) and commission errors (69%; defined as failure to perform a surgical step correctly). Nearly half of all errors went undetected by the residents during the procedure, but when errors were detected, the majority were able to be resolved.
Etherington N, Usama A, Patey AM, et al. BMJ open quality. 2019;8:e000686.
This qualitative study sought to identify barriers and enablers influencing stakeholder support of the Operating Room (OR) Black Box, an audio-video recording device similar to that used on airplanes. Stakeholders were mostly supportive of the OR Black Box, but several potential barriers were identified, such as time pressures in the OR and perceptions that the Black Box may negatively impact clinical performance. Authors concluded that the OR Black Box must be positioned as a patient safety initiative to improve practice.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.