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Arriaga AF, Sweeney RE, Clapp JT, et al. Anesthesiology. 2019;130:1039-1048.
Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.
Badgery-Parker T, Pearson S-A, Dunn S, et al. JAMA Intern Med. 2019;179:499-505.
Overuse of unnecessary tests and procedures contributes to patient harm. In this cohort study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed had longer lengths of stay than patients who did not develop a hospital-acquired condition.
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.
Steelman VM, Shaw C, Shine L, et al. Jt Comm J Qual Patient Saf. 2019;45:249-258.
An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.
Chrouser KL, Xu J, Hallbeck S, et al. Am J Surg. 2018;216:573-584.
Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.
Stucke RS, Kelly JL, Mathis KA, et al. JAMA Surg. 2018;153:1105-1110.
Many states are implementing prescription drug monitoring programs (PDMPs) in an attempt to curb the ongoing opioid epidemic. This single-center study examined the effect of a New Hampshire policy that mandates clinicians use a PDMP and an opioid risk assessment tool prior to prescribing opioids. No impact was found on overall opioid prescribing rates. However, a recent state-level analysis found that states who implemented a PDMP had lower opioid prescribing rates compared to states without PDMPs. A PSNet perspective discussed the factors that contributed to the opioid epidemic and proposed solutions.
Jung JJ, Jüni P, Lebovic G, et al. Ann Surg. 2020;271:122-127.
Analysis of errors in aviation is facilitated by the cockpit "black box," which records flight data as well as communications between team members. This study reports on initial data from the OR Black Box, a novel monitoring technology that integrates continuous monitoring of intraoperative data with video and audio recording of operative procedures. In this initial study of elective laparoscopic procedures, auditory and cognitive distractions were common, and multiple safety events occurred during each procedure.
Joseph A, Bayramzadeh S, Zamani Z, et al. HERD. 2018;11:137-150.
Elements of the work environment can affect the safety of health care delivery. This literature review summarizes research to inform architectural and interior design improvements for operating rooms that support safety. The discussion highlights environmental themes associated with layout, acoustics, and lighting that can affect teamwork, processes, and communication in the operating room.
Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Implement Sci. 2018;13:50.
Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
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.