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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;17:513-521.
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.
Nasca BJ, Bilimoria KY, Yang AD. Jt Comm J Qual Patient Saf. 2021;47:604-607.
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.

Ruskin KJ, ed. Curr Opin Anaesthesiol.  2020;33(6):774-822.

The complexity of care delivery requires complementary approaches to prevent mistakes. This special section shares clinical and organizational tactics to address anesthesiology safety issues. They include automation failures, the role of the obstetric anesthesiologist in maternal safety, and monitoring effectiveness. 

A 56-year-old female received a digital tourniquet around the base of her left big toe during an ablation and excision of a deformed in-grown toenail.

London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.
Ubaldi K. AORN J. 2019;109:435-442.
Safe medication use can be challenging in ambulatory surgery centers. This commentary reviews strategies to improve safety in this setting, including close collaboration with a pharmacist or pharmacy, assessing medication management, and providing clinician education.
Davis KK, Mahishi V, Singal R, et al. J Clin Med Res. 2019;11:7-14.
Ambulatory surgery centers are increasingly utilized to provide surgical care to patients. Quality improvement approaches utilized in the inpatient setting may need to be modified or adapted to be applicable in the ambulatory surgery environment. Researchers describe efforts to implement a surgical safety checklist and infection control techniques across 665 ambulatory surgery centers recruited for the study. They identified several barriers and conclude that the unique aspects of ambulatory surgery centers must be taken into account when implementing quality improvement initiatives.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
Neily J, Soncrant C, Mills PD, et al. JAMA Netw Open. 2018;1:e185147.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.

Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.
Chang B, Kaye AD, Diaz JH, et al. J Patient Saf. 2018;14:9-16.
This retrospective study of the National Anesthesia Clinical Outcomes Registry database determined that complications were more common for procedures performed in the operating room compared to procedures performed outside the operating room. This finding may be due to adverse selection, in which patients at higher risk for complications are intentionally treated in the operating room environment. A past WebM&M commentary discussed an adverse event related to a procedure at an outpatient center.
Health Research & Educational Trust. Rockville, MD: Agency for Healthcare Research and Quality; May 2017. AHRQ Publication No. 16(17)-0019-1-EF.
This report provides information about a national program focused on improving safety in ambulatory surgery. The initiative included surgical safety checklists, webinars, and other tools, with the goal of enhancing safety culture and reducing surgical site infections.
Criscitelli T. AORN J. 2016;103:518-21.
Alarms contribute to distractions, fatigue, and lack of concentration, which can result in patient harm. This commentary examines the problem in ambulatory surgery centers and summarizes resources and recommendations currently available to help staff manage alarms in this setting.
Farag AA, Anthony MK. J Perianesth Nurs. 2015;30:492-503.
This survey study of nurses across four ambulatory surgical wards in Ohio found that nursing managers' leadership styles and some aspects of the safety climate (such as teamwork and organizational learning) were associated with how willing nurses are to report medication errors.
St Paul, MN: Minnesota Department of Health; 2015.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Shapiro FE, Fernando RJ, Urman RD. J Healthc Risk Manag. 2014;33:35-43.
Checklists are an important patient safety intervention in surgery, but existing research has examined their effectiveness only for hospital-based procedures. Although the rate of serious errors in office-based procedures is likely fairly low, safety practices are not standardized in this setting. This survey found that only half of offices performing procedures (which included plastic surgery, gastroenterology, gynecology, and dentistry offices) utilized any type of safety checklist. The main barriers to using checklists were lack of a regulatory mandate and insufficient evidence supporting their effectiveness in this area. A past AHRQ WebM&M commentary discussed a serious error that occurred after a liposuction procedure performed in a plastic surgery office.
In the preoperative area, a man scheduled for excision of a groin lipoma received regional anesthesia (right iliac block) and was taken to the operating room. There, without alerting anyone, the patient attempted to rise to use the restroom, but—because his leg was numb—fell and hit his head. He reported acute neck pain and was transferred to the local emergency department.