Zheng F ed. Surg Clin North Am. 2021;101(1):1-160.
Surgical safety is a recognized area of emphasis in patient safety improvement. Articles in this special issue cover topics such as human factors, checklists, teamwork, and telemedicine as a safe support mechanism.
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
Gavin N, Romney M-LS, Lema PC, et al. BMJ Leader. 2021;5:39-41.
Developed in the field of aviation, crew resource management (CRM) is used to teach teamwork and effective communication and has been used extensively in patient safety improvement efforts. This commentary describes four New York metropolitan area emergency departments’ experience applying (CRM) principles at an organizational level in responding to the current COVID-19 pandemic as well as future crises.
Ruskin KJ, Stiegler MP, Rosenbaum SH, eds. New York, NY: Oxford University Press; 2016. ISBN: 9780199366149.
The perioperative setting is a high-risk environment. This publication discusses the clinical foundations and application of safety concepts in perioperative practice. Chapters cover topics such as human factors, error management, cognitive aids, safety culture, and teamwork.
Davidson M, Brennan PA. Br J Oral Maxillofac Surg. 2019;57:407-411.
Aviation has provided health care with insights regarding how systems approaches, blame-free reporting, and teamwork can prevent failure. This commentary summarizes tactics used in aviation that have been applied to surgery in support of efforts to reduce patient harm.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
Clearfield C, Tilcsik A. New York, NY: Penguin Press; 2018. ISBN: 978-0735222632.
Complex systems are prone to failure. This book provides a multi-industry discussion of factors that contribute to failure. The authors highlight how complexity can exacerbate problems, small glitches can manifest themselves in large-scale failure, and poorly designed safety strategies can unintentionally contribute to harm. Recommended strategies to manage risks include those utilized in patient safety work, such as multidisciplinary teamwork, process design, and systems thinking.
Elmontsri M, Banarsee R, Majeed A. JRSM Open. 2018;9:2054270418786112.
Health care safety is a global concern. This review examined the literature on improvement experience from developed countries and identified common themes. The authors recommend a patient-centered, systems-oriented approach built on leadership, teamwork, transparency, and communication as key elements for effectively implementing improvement efforts in developing countries.
Jones TS, Black IH, Robinson TN, et al. Anesthesiology. 2019;130:492-501.
Surgical fires, though uncommon, can result in serious harm. This review highlights three components to be managed in the operating room to prevent fires: an oxidizer, an ignition source, and a fuel. The authors provide recommendations to ensure each element is handled safely.
Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.
Articles in this special issue apply safety concepts to reducing preventable patient harm in otolaryngology. The reviews highlight systems science, collaboration, leadership models, and patient experience as important to moving safety innovation forward in this specialty.
Bach TA, Berglund L-M, Turk E. BMJ Open Qual. 2018;7:e000202.
Alarm fatigue limits the utility of physiologic monitoring devices intended to keep hospitalized patients safe. The authors conducted a literature review and interviewed experts to identify best practices to optimize device alarms. They present a step-by-step guide to alarm improvement that incorporates a human factors engineering approach.
Systems solutions are often focused on creating improvements at the organizational or blunt end. This commentary argues that the concept has relevance at the sharp end as well. The author explores the role of clinical teams in applying systems thinking to reduce blame, improve learning from harm, and address persistent challenges to patient safety.
Pannick S, Athanasiou T, Long SJ, et al. BMJ Open. 2017;7:e014333.
This prospective trial with concurrent controls examined whether frontline team safety surveillance reduced the instances of longer-than-average length of stay for a given diagnosis. The study team found that incomplete implementation of the intervention actually increased length of stay, whereas stringent implementation of the intervention improved length of stay. The authors conclude that suboptimal implementation can negatively affect safety.
Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-AP4.
Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.
Cabral RA, Eggenberger T, Keller K, et al. AORN J. 2016;104:206-216.
Surgical team communication is an important element of safe care. This project report describes how one hospital implemented a checklist program that utilized time outs and debriefings to support transparency and improve surgical teamwork behaviors.
Singer SJ, Molina G, Li Z, et al. J Am Coll Surg. 2016;223:568-580.e2.
Although checklists have been shown to improve safety and surgical mortality, they can be difficult to implement, which limits their effectiveness in clinical practice. This study examined whether perceptions of teamwork predicted checklist performance. Trained observers used standardized tools to rate the extent of checklist completion and quality of teamwork. They found that checklists were implemented as intended in only 3% of cases. Surgical teams with better surgeon buy-in to checklists, clinical leadership, communication, and overall teamwork completed more checklist components. Clinical factors, including older patient age and longer duration of surgery, were also associated with performing more of the checklist. The authors suggest that teamwork is critical to checklist implementation. A PSNet interview discussed the challenges of implementing checklists in health care.
Ong APC, Devcich DA, Hannam J, et al. BMJ Qual Saf. 2016;25:971-976.
This hospital introduced large print, wall-mounted checklist posters in their operating rooms (ORs) and specifically assigned the leadership of each domain of the checklist to a different OR group (anesthesia, nursing, and surgery). These inexpensive changes led to improvements in team engagement and compliance with the surgical safety checklist process.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.