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De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16(9):e0257508.
Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks.  This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.

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.
Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;233(6):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
Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2021;Epub Oct 28.
Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.
Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2(3):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.

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. 
Ranum D, Beverly A, Shapiro FE, et al. J Patient Saf. 2021;17(7):513-521.
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.
Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59(7):752-756.
Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.
Sidi A, Gravenstein N, Vasilopoulos T, et al. J Patient Saf. 2021;17(6):e490-e496.
Nontechnical skills, such as teamwork and communication, can influence performance in technical fields like surgery or emergency medicine. This study found that simulation-based assessments can measure improvements in nontechnical skills and cognitive performance among residents.

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period is closed.
Cohen JB, Patel SY. Anesth Analg. 2021;133(3):816-820.
Designated safety leadership roles are situated to direct and sustain organizational safety progress. This commentary describes an anesthesiology safety officer function and how it is positioned to motivate staff safety behaviors and support engagement during project challenges.
Nasca BJ, Bilimoria KY, Yang AD. Jt Comm J Qual Patient Saf. 2021;47(9):604-607.
Surgical safety has made advances while new difficulties continuously emerge. This article suggests that the specialties capitalize on artificial intelligence and professional wellness as two avenues to generate sustainable safety progress.
Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127(3):470-478.
Effective communication among providers helps ensure patient safety. Through analysis of perioperative malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures contributed to 43% of total claims, with the majority between the anesthesiologist/anesthesia team and the surgeon/surgery team. Methods to improve perioperative communication are discussed.
Nanji K. UpToDate. Aug 11, 2021.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Bubric KA, Biesbroek SL, Laberge JC, et al. Jt Comm J Qual Patient Saf. 2021;47(9):556-562.
Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure.

Casciato DJ, Thompson J, Law R, et al. J Foot Ankle Surg. 2021;60(6):1152-1157.
The "July Effect" refers to the idea there may be an increase in medical errors in July when newly graduated medical students begin their residencies. In this retrospective chart review of podiatric surgery patients, researchers did not find any statistically significant difference in patient outcomes between surgeries performed during the first quarter of residency (July-September) and the last quarter (April-June). Results suggest robust resident training programs can limit errors that may otherwise occur during this time of transition.  

A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed.

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.