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This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.

Warner MA, Warner ME. Anesthesiology. 2021;135(6):963-974.
The legacy of anesthesiology as a leader in patient safety is reviewed as a model for other communities seeking to reduce medical error. The authors highlight the collaboration strategies that the specialty embraced as a key component of its success.
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22(12):2553-2558.e1.
Medication reconciliation has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.

Ehrenwerth J. UptoDate. November 5, 2021.

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. The deadline for submitting data is February 11, 2022.

Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi: 

Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. A related webinar will be held February 2, 2022.
Hammond Mobilio M, Paradis E, Moulton C-A. Am J Surg. 2021;Epub Nov 24.
Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.
Malahias M-A, Antoniadou T, Jang SJ, et al. J Am Acad Orthop Surg. 2021;29(24):e1387-e1395.
Previous research has raised concerns about safety risks associated with overlapping surgery, defined as two procedures performed concurrently, but where critical surgical portions of each procedure occur at different times. Based on a meta-analysis of six articles, the authors of this systematic review found that rates of surgical complications readmissions were similar among overlapping and nonoverlapping surgery in patients undergoing total joint arthroscopy.

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.

Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Wallis CJD, Jerath A, Coburn N, et al. JAMA Surg. 2021;Epub Dec 9.
Gender, racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor outcomes. This retrospective study examined surgeon-patient sex discordance and perioperative outcomes among adult patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to 2019. Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant increased likelihood of adverse perioperative outcomes, including death. Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients treated by male surgeons.
Brown B, Bermingham S, Vermeulen M, et al. BMJ Open Qual. 2021;10(4):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.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55(1).
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Liu C, McKenzie A, Sutkin G. J Surg Edu. 2021;78(6):1938-1947.
Communication failures are a common cause of patient harm. This qualitative study found that potentially ambiguous language is common in surgical training settings. In addition to creating challenges for trainee comprehension of surgical instruction, ambiguous language can lead to miscommunications and near misses.

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.
Gillespie BM, Harbeck EL, Rattray M, et al. Int J Surg. 2021;95:106136.
Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).

ECRI and Institute for Safe Medication Practices. January 2022 through May 2022.

Collaboratives provide teams with active learning and improvement opportunities based on the experiences of others working toward a collective goal. This collaborative will target safety during surgical procedures. The discussions protected under the sponsors’ Patient Safety Organization status will explore improvement topics such as medication errors and surgical site infections.
Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28(13):8109-8115.
While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.
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.