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The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps

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January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.

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Brown B, Bermingham S, Vermeulen M, et al. BMJ Open Qual. 2021;10:e001593.

Despite evidence of the benefits of the World Health Organization’s surgical safety checklist, implementation and sustainability are inconsistent in many hospitals. Using five cycles of Plan-Do-Study-Act, a hospital in Adelaide, South Australia, was able to increase use of the checklist from 3.5% to 63%. Staff reported that they felt the new checklist process improved patient safety and was easily incorporated into their workflow.

Age-related COVID-19 vaccine mix-ups.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021.

Vaccine missteps are known to occur during flu and COVID-19 inoculation efforts. This announcement raises awareness of misadministration of COVID vaccines associated with patient age. It highlights storage protocols as one approach to minimize mistakes. This alert is part of a national program to distribute learnings from report analysis to improve medication safety.

Technology, Education and Safety.

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Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.

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November 30, 2021

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

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Walton E, Charles M, Morrish W, et al. J Patient Saf. 2022;18:e620-e625.

Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.

Pediatric medication errors and reduction strategies in the perioperative period.

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Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.

Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.

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Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;233:794-809.e8.

The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

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Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2:e075.

The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.

Influence of perioperative handoffs on complications and outcomes.

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Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.

Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.

Causes of use errors in ventilation devices--systematic review.

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Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.

Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.

Prevention of failure to rescue in obstetric patients: a realist review.

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Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.

Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.

Conflict resolution: applying aviation crew resource management in healthcare.

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Braverman A. Nurs Manage. 2021;52:30-34.

In high-consequence environments, differences of opinion can undermine teamwork and result in operational failure. This article discusses the application of crew resource management (CRM) to the clinical environment. The author outlines steps to translate the aviation CRM experience into the health care domain to improve communication and resolve conflicts in stressful situations.

Adaptation and implementation of the WHO Safe Childbirth Checklist around the world.

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Molina RL, Benski A-C, Bobanski L, et al. Implement Sci Commun. 2021;2:76.

Checklists are widely used to improve patient safety, including reductions in catheter-related bloodstream infections and surgical morbidity and mortality. This study focuses on implementation of the 2015 World Health Organization Safe Childbirth Checklist (SCC) which aims to prevent maternal and neonatal morbidity and mortality. Twenty-nine participants from fifteen countries with SCC experience completed a survey and twelve were interviewed. Most reported adapting the SCC for their local setting and a wide variety of implementation strategies were used.

Awareness of human factors in the operating theatres during the COVID-19 pandemic

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October 27, 2021

Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms.

The Hidden Danger of Unseen Intravenous Catheters

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October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.

Dashboards for visual display of patient safety data: a systematic review.

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Murphy DR, Savoy A, Satterly T, et al. BMJ Health Care Inform. Epub 2021 Oct 8.

Dashboards can provide real-time quality and safety data to frontline providers. This systematic review found limited information on the direct impact of patient safety dashboards on reducing patient safety events. The authors also note that dashboard design processes are rarely based on informatics or human factors principles, which may impede implementation and use.

Adopting system models for multiple incident analysis: utility and usability.

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Wheway JL, Jun GT. Int J Qual Health Care. 2021;33:mzab135.

This qualitative study conducted in the United Kingdom evaluated the utility of two system models – AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) – to better understand patient safety incident reports and develop remedial actions. Participants appreciated the unique strengths of both models but expressed concerns regarding their complexity and required training/education.

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

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Randall KH, Slovensky D, Weech-Maldonado R, et al. Pediatr Qual Saf. 2021;6:e470.

Achieving high reliability is an ongoing goal for health care. This survey of 25 pediatric organizations participating in a patient safety collaborative identified an inverse association between safety culture and patient harm, but found that elements of high-reliability, leadership, and process improvement were not associated with reduced patient harm.

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