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Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2022;41:25-29.
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.
Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16:255-258.
Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.
Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16:41-46.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Steinberger DM, Douglas S, Kirschbaum MS. Prog Transplant. 2009;19:208-14; quiz 215.
Failure mode and effects analysis was used to identify vulnerable handoff and communication processes in organ procurement and transplantation. A communication error led to the widely publicized death of a lung transplant patient at Duke University Medical Center in 2003.
Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-83.
This study used a trained observer to monitor obstetric patients for potential adverse events. Based on a predefined set of 72 triggers (eg, admission to intensive care unit, stat cesarean delivery, staff unavailability), the observer captured relevant information about the events, which were later analyzed by a multidisciplinary team. Investigators identified more than 100 triggers, and while very few serious adverse events were described, a number of potential adverse events raised questions about system problems. The authors advocate for use of their methodology to complement existing mechanisms in collecting information on adverse events.
Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-63.
This cohort study examined the relationship between surgery start time and anesthetic adverse events (AEs) using a large database of anesthesia procedures at an academic medical center. The incidence of AEs was increased for surgical procedures starting in the late afternoon compared with those starting in the morning. The authors hypothesize that this finding could reflect fatigue (as demonstrated in a prior simulation study) or problems with care transitions; however, they were not able to directly measure case load or composition of the care team. Moreover, for most AEs, the authors could not determine whether patients were harmed or whether the error was preventable.